JUDGMENT 1. - A letter petition dated 30.1.99 addressed to the Chief justice and companion Judges of this Court, by one Shri Deepak Jain son of K.N. Jain, 14, Ganga Path, Suraj Nagar (West), Civil Lines, Jaipur was entered by the Registry of this Court on 26.3.1999, and on 3.8.99, it was listed before the Division Bench. The Division bench requested Shri N.K. Joshi, Advocate to appear as an Amicus Curiae in this letter petition. Notices of this petition were issued to the Secretary to the Government, Medical and Health Department, State of Rajasthan and the Supdt. SMS Hospital, Jaipur on 6.9.99, It may be pointed out that the letter petition was based on a news item published in the daily issue dated 30.1.99 of a local newspaper-with the heading "OPERATION THEATRE ME PANAPNE LAGE HAI JANLEVA KITANU" (SAWAI MAN SINGH ASPATAL). A reply dated 21.2.2000, to the petition was filed on behalf of the respondents. The matter has been pending since 1999 and orders have been passed, from time to time. We may make reference to the orders dated 22.11.2000, 14.5.2001, 12.9.2001, 10.12.2001, 3.1.2002, 9.1.2002, 5.2.2002, 5.4.2002, 12.7.2002, 2.8.2002 and 7.8.2002. A perusal of the order sheet dated 22.11.2000 would show that a Committee was appointed as mentioned in this order and this Committee was to make the report in respect of the conditions prevailing in the operation theatres and other premises of the SMS Hospital, Jaipur, as early as possible, preferably within one month. On 14.5.2001, Mr. Dalip Singh, Advocate, one of the members of the Committee as constituted by the court's order dated 22.11.2002, sought to be relieved from the membership of the Committee and therefore, the Court directed the other members of the Committee to submit their report within one month from 14.5.2001. On 12.9.2001, it was recorded that for personal reasons, another member namely Shri S.R. Bajwa also sought to withdraw his name from the Committee and therefore, the Division Bench directed the Secretary to Government, Medical and Health Department, Government of Rajasthan, Jaipur to constitute a Committee including three senior Professors working in the SMS Medical College, Jaipur. It was also directed that such Committee may also include a senior officer to be nominated by the Finance Department as also an officer to be nominated by the Chairman, Rajasthan State Pollution Control Board, Jaipur. It was also directed that such Committee may also include a senior officer to be nominated by the Finance Department as also an officer to be nominated by the Chairman, Rajasthan State Pollution Control Board, Jaipur. The Committee was required to submit its report not only with regard to the present conditions of the Operation theatres and other premises of the SMS Hospital, Jaipur but also to suggest the remedial measures and the Secretary to Government, Medical and Health Department was directed to constitute the Committee within fifteen days of the receipt of copy of the order and the Committee so constituted was to submit its report by 3.12.2001. On 10.12.2001, it was recorded that the report of the Committee had been received and the Health Secretary as well as the hospital authorities were granted time to examine the report and the matter was directed to be listed on 3.1.2002 to have the comments of the State Government as well as the hospital authorities on this report. On 3.1.2002, it was told before the Court by Shri N.K. Joshi, Advocate appearing for the petitioner as Amicus Curiae, that there were no suggestions in the report on the question of process which was required to be undertaken daily to prevent bacterial infection in the Wards and other areas in the hospital premises and no details had been furnished in this regard. On 3.1.2002 itself, the hospital authorities were directed to place on record the details about the daily process for prevention of bacterial infection which was required to be undertaken in the hospital building, wards and outside the wards as also details and the intervals at which the operation theatres were fumigated in the year 2001 and the duration of intervals at which the various operation theatres were being fumigated. The relevant record maintained by the hospital authorities in this regard was directed to be produced. The comments of the State Government were also sought on this report on 3.1.2002 and the matter was posted for 9.1.2002, on which date the matter had been heard but the same had been kept pending for further hearing and for dictating the detailed directions and to monitor the implementation. 2. On 5.4.2002, one Shri R.L. Jain, Advocate had moved an application that he wanted to assist the Court in this public interest litigation and his application was allowed. 2. On 5.4.2002, one Shri R.L. Jain, Advocate had moved an application that he wanted to assist the Court in this public interest litigation and his application was allowed. On 12.7.2002, while Shri S.M. Mehta, learned Advocate General was present to assist the Court in the matter, the departmental panel lawyer was not available to apprise the court about the further steps taken by the hospital authorities. Shri N.K. Joshi, appearing for the petitioner had filed a memo of suggestions for the purpose of better management of the institution, certain places - adjoining or adjacent to the hospital campus and it was also pointed out that for the purpose of management of private hospitals, a report had been made by Dr. S.R. Mehta (Retired Principal, SMS Medical College, Jaipur) and the same had been submitted to the Government. It was further submitted that the suggestions as were made in that report may be useful for the purpose of giving appropriate directions in this matter and therefore, the learned Advocate General was asked to produce a copy of the said report on the relevant portions thereof before this Court so that it could be seen as to whether any help could be taken from the suggestions/recommendations made in this report for the purpose of issuing appropriate directions with regard to the better management of the SMS Hospital. 3. Shri S.P. Mathur, Advocate pointed out that recently a Conference had been held on the hospital management at Jaipur and the report of this Conference may also be useful. The authorities were therefore, directed to produce such report also. On 2.8.2002, copy of the report, as had been submitted by Dr. S.R.-Mehta, was produced before us by the learned Advocate General. 4. Shri R.L. Jain, Advocate produced before us the notification issued by the Ministry of Environment and Forests, dated 20th July, 1998 along with the amnedments and wanted us to go through the same. 5. Thereafter, on 7.8.2002, we made a query as to whether the report submitted by Dr. S.R. Mehta had been accepted by the Government or not and on that day, the report of the International Seminar on Hosputal Waste Management, Delhi was also produced. The issue with regard to the de-congestion of the wards in the Hospital was also raised. 5. Thereafter, on 7.8.2002, we made a query as to whether the report submitted by Dr. S.R. Mehta had been accepted by the Government or not and on that day, the report of the International Seminar on Hosputal Waste Management, Delhi was also produced. The issue with regard to the de-congestion of the wards in the Hospital was also raised. It was also pointed out by Shri N.K. Joshi that important machines had been purchased at very high price and the same are lying un-used in the Hospital and therefore, the price of each such equipment with date of purchase and the reasons for the same not being used were called for. The matter came up lastly before the Court on 2.8.2002 and it was posted for final disposal on 9.8.2002, on which date all the parties were heard and this is how the matter comes up today before us for dictation of directions in this public interest litigation. 6. We have considered the entire material which has come on record and first of all, we may deal with the report made by Dr. S.R. Mehta and as to what directions can be given on that basis for the better management of the Government hospitals, though essentially, the report was sought with orientation of the urgent need to lay down minimum norms and standards for registration and accreditation of the hospitals through legislation as was strongly recommended by the Medical Council of India in collaboration with the Government of India and World Health Organisation by organising two Workshops in the year 1999 and 2001. The National Human Rights Commission had even went a step ahead and assumed the responsibility of examining the functioning of psychiatric health establishments and prescribed norms and standards for psychiatric institutions to protect the rights of patients in view of increasing complaints and the same were made mandatory by the Supreme Court of India. It was in this background that the Government of Rajasthan led the way to implement the recommendations of the Medical Council of India, Government of India and the World Health Organisation workshop and formed Dr. S.R. Mehta Committee requiring it to submit recommendations for improving the state of affairs in private health sector so that public could get better facilities and quality services at the reasonable cost. S.R. Mehta Committee requiring it to submit recommendations for improving the state of affairs in private health sector so that public could get better facilities and quality services at the reasonable cost. We have gone through several portions of this report and we find that the Committee has undertaken lot of pains and has worked hard to prepare norms and standards after deliberations and consultation with the large number of professional experts and general practitioners and has studied the relevant literature as quoted in the report. Due weight has been given to the recommendations of the Bureau of Indian Standards. We find that the Committee has done a commendable work and its report in two volumes may be highly useful in laying down the norms and standards for registration and accreditation of the hospitals through legislation. However, before the same is taken up for private hospitals, we may make use of this report while giving the directions with respect to the items which are common to the management of the private hospitals as well as Government hospitals, as under and for that purpose, reference may be made to the contents of, the report indicated against each of the items as under : 1. Out Patient Department 563-596 (Vol.II) 2. General requirement that need to be met by all 602-607 (Vol.II) clinical establishments. (except items 2a, 2b, 7, 8, 15, 16, 18, 26 and 31) 602-607 (Vol.II) 3. Basic general requirements need to be met by all hospitals: a. In-patient Unit 610-613 (Vol.II) b. Emergency Services 613-614 (Vol.II) c. Operation Theatre Suite 614-617 (Vol. II) d. Delivery Unit Suite 618-619 (Vol.II) e. Intensive Care Unit 619-634 (Vol.II) f. Anaesthesia equipment 634 (Vol II) g. Physiotherapy Department 760-762 (Vol.II) h. Requirements and Norms for Nursing Staff 141-143 (VOLT) i. General Instruments Equipments and Furniture requirement for different functional area. 636-654 (Vol.II) j. Hospital Services 656-660 (Vol.II) 4. Guidelines for Qualify Assurance in Hospital Services. 662-693 (Vol.II) 5. Requirements that need to be met by Speciality Deptt./Hospital. 763-837 (Vol.II) 6. Norms and Standards for Diagnostic Centres 838-864 (Vol.II) 7. Guidelines for evaluation and assessment of the performance and functioning of the Institution. 205-210 (Vol.I) 8. Personnel Development 205-205 (Vol.I) 7. 636-654 (Vol.II) j. Hospital Services 656-660 (Vol.II) 4. Guidelines for Qualify Assurance in Hospital Services. 662-693 (Vol.II) 5. Requirements that need to be met by Speciality Deptt./Hospital. 763-837 (Vol.II) 6. Norms and Standards for Diagnostic Centres 838-864 (Vol.II) 7. Guidelines for evaluation and assessment of the performance and functioning of the Institution. 205-210 (Vol.I) 8. Personnel Development 205-205 (Vol.I) 7. We find from the report which was filed in this Court on 24.11.2001 that a mention has been made therein about the status of hygiene with reference to operation theatres, operating staff, instruments, patients, attendants and visitors, light, water and toilet facilities, space and accommodation and thereafter, the recommendations have been made. At page 12 of this report, it has been clearly stated that the hygienic conditions inside the hospital building cannot be termed as satisfactory and thousands of patients, attendants and visitors come to the hospital daily and it is difficult to maintain hygienic conditions in the building. It has also been mentioned in this report that the facilities of toilet are far from satisfactory and most of the toilets are dirty and in very bad shape. This Committee has also lamented about the conditions of coolers and condemned articles, drinking water facilities, entry of cows, stray animals and street dogs etc. into the hospital and thereafter, certain suggestions for improvement of the hygiene inside the hospital building (page 15-25 of the Report) have been given and for hygiene outside the hospital premises, suggestions are at page 26. We find that all the suggestions are useful but the same are of general nature only. In any case they have to be followed but drastic measures are required to be taken for the improvement of hygienic conditions in the hospital right from the operation theatres, Wards and various parts of the building of the hospital and the entire hospital premises as such. 8. SMS Hospital is a large Institution in the northern India. It is a major centre for treatment not only for Rajasthan but also for adjoining States. 9. The availability of professionally competent Doctors and economically affordable cost are its special features. With a little reorganisation and better management, the things could be vastly improved without significant extra cost. Since there are common problems of different nature faced by the common man in this hospital, we give directions for different items as under :1. 9. The availability of professionally competent Doctors and economically affordable cost are its special features. With a little reorganisation and better management, the things could be vastly improved without significant extra cost. Since there are common problems of different nature faced by the common man in this hospital, we give directions for different items as under :1. HYGIENE (a) The equipments which are used in the operation theatres must be regularly subjected to auto clave and each and every item which is used in the operation theatre must be treated with dis-infactants. (b) Operation Theatres must be fumigated at regular intervals (the period of interval must be weekly or as per prescribed norms) and record of such fumigation is to be kept in the regularly maintained registers, and a certificate of 'Zero Bacteria' must be obtained from the Bacteriological Department for every operation theatre which is in use. (c) In the Wards of the Hospital also, there must be use of dis-infactant agents and anti-bacterial gas and they must be regularly cleaned and swept with Phenyl or other anti-bacterial agent at a regular interval of few hours. (d) Each Ward of the Hospital should have facility of clean drinking water. The maintenance of coolers/fans and water taps should be given under annual maintenance contract. The Basement Store Incharge/R.M.O./Caretaker should be made accountable to supervise the maintenance. (e) Care is to be taken to sweep the Wards and the Verandas, Passages and other places where visitors and attendants pass through so that they remain dean and the spittoons which are placed must also be cleaned from time to time and at regular intervals of few hours. (f) The toilets/bathrooms be provided in adequate number and maintained with cleanliness. The cleanliness contract could be given to private organisation and if need be, the cost of maintenance be charged or donations arranged. The supervision should be left in the hands of Caretaker and his team. The R.M.O. and Deputy Medical Superintendent should be made accountable. (g) Proper facility of stay of attendants could be arranged by close co-ordination with owners of Dharamshalas. (h) Entry of the attendants and visitors must be regulated by fixing the visiting hours and arrangements have to be made that even if there is no personal attendant with the patient, he is fully attended through the nursing and other hospital staff. (g) Proper facility of stay of attendants could be arranged by close co-ordination with owners of Dharamshalas. (h) Entry of the attendants and visitors must be regulated by fixing the visiting hours and arrangements have to be made that even if there is no personal attendant with the patient, he is fully attended through the nursing and other hospital staff. (i) For the purpose of decongestion in the hospital, admissions must be restricted only to the extent of the capacity. In case the capacity is not adequate corresponding to the inflow, arrangements be first made to increase the capacity so as to meet the requirement reasonably. (j) Number of beds to a particular department shall be reckoned as per the occupancy rate and the bed strength shall be reorganised. No patient shall be made to lie on the ground and every indoor patient shall be provided with a bed. Discharge and turnout of the indoor patients shall be. increased with large waiting time in as much as patients can be discharged for planned surgery and no patient shall be allowed to remain on the floor. (k) The availability of clean bed sheets when the patient is admitted is a must and shall be ensured. Periodic change of bed sheet to be given at cost. A Bed Sheet Store could be proposed. (l) A separate emergency for Accident and Orthopedic cases may be located near the Orthopedic Rehabilitation Centre eventually by raising new building to the North of the Rehabilitation Centre and the Orthopedic OPD, Orthopedic Wards, male and female, may also be located in that very building. The site of residential quarters located to the North of the Rehabilitation Centre can be used for housing separate Orthopedic Emergency, OPD, Orthopedic Wards, to reduce the number of patients/attendants entering the main building. (m) One Single OPD for other cases (except Neurology/Urology) should be provided. The patients coming to this Hospital are put to baffling situation when one OPD refers the patient to other OPD and some times he is still referred to the third OPD. Creation of single OPD for all other cases would be convenient and less time consuming for the patients and would facilitate mutual consultation between doctors manning different OPDs making the services to the patients more effective. Creation of single OPD for all other cases would be convenient and less time consuming for the patients and would facilitate mutual consultation between doctors manning different OPDs making the services to the patients more effective. (n) A separate emergency with in-built emergency operative case unit be provided for giving better care to other type of emergency cases. II. Basic facilities/equipments etc. to be provided in the hospital: (a) Magnetic Resonance Imaging (M.R.I.) (equipment lacking in the Hospital). (b) Gama Imaging (Equipment lying unused for last ten years). (c) C.T. Scan (one equipment available) but going in, disuse frequently. Looking to the number of patients, one more equipment should be installed. (d) Cath Lab should be equipped with latest technology as the equipments are completely outdated. (e) Maintenance and repairs of the equipments/machineries should be ensured and a system of regular maintenance and repairs of the equipments should be evolved. (f) There should be Separate cardiac/coronary ICU. There being no separate cardiac/coronary ICU Unit, cardiac patients who need Special care by Cardiologists/Cardiac Surgeons are put in general medical ICU where the needed facilities cannot be effectively provided to cardiac patients. Moreover, by keeping serious cardiac patients who may be quite prone to infections along with other patients in general ICU, the number of casualties/death are likely to be higher. (g) A new wing of I.C.U. could be immediately planned for medical patients. This should have a semi I.C.U. to avoid congestion for other patients and recovery cases. The present I. C.U. is inadequate and a lot of patients have to leave the place for costly hospital admission in private sector. (h) A poly wing hospital lab, radiology facility etc. near the emergency wing be established. Coronary/Cardiac ambulances have to be provided. Ambulances for Coronary/Cardiac cases, equipped with all cardiac emergency facilities should be provided which would go a long way so as to save lives to patients who may succumb on their way to the Hospital. (i) Bacterial infection in operation theatres and ICUs be taken care of: To cope with the high influx of patients, two more operation theatres should be provided with the latest techniques and the existing operation theatres should also be equipped according to prevalent international standards and at the same time, the number of beds in Medical ICU, should be doubled. (i) Bacterial infection in operation theatres and ICUs be taken care of: To cope with the high influx of patients, two more operation theatres should be provided with the latest techniques and the existing operation theatres should also be equipped according to prevalent international standards and at the same time, the number of beds in Medical ICU, should be doubled. (j) Looking to the number of patients coming in the Hospital, the number of doctors is insufficient and the nursing staff is also insufficient with the result that despite competent doctors serving the hospital, the patients do not get the required attention and medicare. The staff which has to take care including Junior Surgeons in operation theatres which have to be run after normal hours and even in the night to handle emergency cases has to be made adequate. (k) to strengthen the infrastructure, the staff of the junior level posts in various departments will have to be increased and extra nursing staff is to be provided. It is thus directed that sufficient number of doctors and nursing staff should be provided to make the services rendered by the hospital efficient. (l) The reduplication of machines purchased shall be stopped. Each speciality department shall co-ordinate to avoid this with the Superintendent alone. (m) The hospital must have service contracts with regard to each and every equipment so that no equipment ever remains unused. (n) The State Government will be well advised to have a separate Medical Suptd. of the Hospital and a separate Suptd. as the Hospital Administrator who may be qualified in the branch of hospital management and the hospital must be managed by the Administrator who is qualified in hospital management and not by those who are essentially doctors in their own specialities and super-specialities; and services of such doctors or teachers who are members of the collegiate branch service should not be utilised for management of the hospital as Administrator and the concept of Medical Supdt. as the over all incharge and the Hospital Administrator (who is qualified in hospital management) under him must be evolved out and put into practice for the purpose of proper maintenance of the building as well as medical facilities in the hospital. as the over all incharge and the Hospital Administrator (who is qualified in hospital management) under him must be evolved out and put into practice for the purpose of proper maintenance of the building as well as medical facilities in the hospital. (o) For the purpose of diagnosis, the facilities have to be made available within the hospital itself instead of sending and referring the patients to the private diagnostic clinics where they have to pay the money which they can hardly afford and it is to be seen that no patient is forced to avail the diagnostic services in the private diagnostic clinics/centres/laboratories for which facilities can be readily made available in the hospital itself. (p) CANTEEN: There is no canteen in the Hospital premises with the result that the patients, attendants as also the doctors and the members of the staff have to depend on the outside catering which is unhygienic. The patients and their attendants have to depend on the 'The law alas' standing outside the hospital. It is therefore, necessary that a canteen should be provided in the hospital premises itself. A large canteen be planned for patients and attendants for providing food, snacks, tea etc. on subsidised rates and for this purpose, Basement could be the ideal area. (q) Disposal of waste material Disposal of waste material of the hospital should be done in accordance with the provisions of the Environment (Protection) Act, 1986 and scientific measures against the Hospital Acquired Infections, disposal of bio-medical waste, application of waste management and treatment technologies and safety measures for handling and disposal of hospital waste should be taken. (r) No proper facility for patients in waiting is available in any outdoor. The waiting spaces are crammed; no fans or drinking water facilities are available. (s) There should be a separate outdoor wing or building where different general and speciality professionals are available under one roof. They should be supported by specialist from other Hospital - One unit of each like Dental/Psychiatry/Gynae. This could prevent too much running here and there for a single patient requires many referrals. OPD facility under one roof shall decongest the hospital significantly. (t) It would be ideal to have well equipped OPD Labs. with full Radiology set up adjacent to the OPD Wing. Patient could himself get investigated, get his report and consult the doctor on the same day in the evening. OPD facility under one roof shall decongest the hospital significantly. (t) It would be ideal to have well equipped OPD Labs. with full Radiology set up adjacent to the OPD Wing. Patient could himself get investigated, get his report and consult the doctor on the same day in the evening. (u) Each wing should have the cooperative fair price drug shops. In fact these could be a useful source of income to the Hospital. (v) The hospital should give a decent look, noise pollution free and clean. The small vendors around the boundary of the hospital shall be rehabilitated at some other places by the Municipal authorities and it will be the duty of the Dy. Commissioner of Municipal Council to see that no encroachment is made again and he shall be made accountable for the same and in case any negligence is shown in this regard, the concerned officer who is found to be accountable shall be liable for appropriate action including an action for showing scant regard to the directions of the Court. (w) The cycle/scooter stand/parking for cars etc. shall be provided underground, and the areas which are presently occupied shall be converted into green zones so that the size of the lung in hospital area which has considerably shrunken, gets adequate space for breathing and other vacant places/land in the hospital premises shall be converted to green. (x) The kiosks which have been provided shall be made use of for actual shop by those to whom the same have been allotted, rather than being used as store. (y) Information service be improved significantly. Females should man the Reception area. Like the international patient care service centre in larger Hospital, some similar facility should be developed. The Hospital EPABX staff and attendants have to be made alert to promptly attend the phone calls and not to sleep or leave their seat and leave the phone calls unattended to avoid the public feeling that even in hospital the phone calls are not attended. The Hospital EPABX staff and attendants have to be made alert to promptly attend the phone calls and not to sleep or leave their seat and leave the phone calls unattended to avoid the public feeling that even in hospital the phone calls are not attended. (z) Steps may also be taken that, to take care of the litigation, for and against the hospital, no working doctor or teaching doctor of the Collegiate Branch should be appointed as the Officer Incharge of the case and instead, the Legal Assistants, Head Legal Assistant or the officer concerned in the ministerial staff or member from the Rajasthan Secretariat Service i.e. those who are conversant with the cases, must be appointed as the Officer Incharge and the time which the doctors are supposed to devote to the patients and in operative cases, should not be consumed to take care of the litigation. 10. So far financial aspect for giving effect to the directions is concerned, we may observe that the learned Advocate General has stated before us that there are no financial constraints for the purpose of improvement and better management of the hospital which is the premier hospital of the State and for that purpose, Rajasthan Medical Relief Society is there to fund apart from the State Govt. Even then, we may clarify that if at all, there is any problem of finances and any financial constraints are involved, such directions may be carried out in a phased programme to achieve the ultimate goal. The Medical and Health Department may hire the services of any retired Army Officer of high rank to maintain the discipline and hygienic conditions and it may also constitute a Committee of expert and experienced senior retired doctors or such other doctors or dignitaries who have remained associated with this hospital and have desire to see this premier institution of this State in a position which we cherish the most. In this regard, a bi-monthly progress report shall be filed in this Court and it will also be open for the petitioner and others acting in public interest to bring it to the notice of the Court, if the directions Oven by this Court are not acted upon and given effect to, and in case the directions are not carried out in letter and spirit. A stock of the situation has to be taken after every two months and the matter shall be listed on the first working day in the first week of every second month. 11. With the illustrative but not exhaustive directions, as aforesaid, this petition in public interest is decided with the hope and belief that the responsive Government would give a serious, quicker and readier response to these directions.Petition decided. *******