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Home > Design Guidance > Building Types > Health Care Facilities > Hospital

by Robert F. Carr NIKA Technologies, Inc. for VA Office of Construction & Facility Management (CFM) Revised by the WBDG Health Care Subcommittee Last updated: 12-30-2010

"A functional design can promote skill, economy, conveniences, and comforts; a non-functional design can impede activities of all types, detract from quality of care, and raise costs to intolerable levels." ... Hardy and Lammers

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Hospital

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RELAT ED RESO URCE PAGES

Achieving Sustainable Site Design through Low Impact Development Practices Aesthetic Challenges

Within This Page Overview Building Attributes Emerging Issues Relevant Codes and

Standards Ho spitals are the mo st co mplex o f building types. Each ho spital Major Resources is co mprised o f a wide range o f services and functio nal units.

These include diagno stic and treatment functio ns, such as clinical labo rato ries, imaging, emergency ro o ms, and surgery; ho spitality functio ns, such as fo o d service and ho usekeeping; and the fundamental inpatient care o r bedrelated functio n. This diversity is reflected in the breadth and specificity o f regulatio ns, co des, and o versight that go vern ho spital co nstructio n and o peratio ns. Each o f the wide-ranging and co nstantly evo lving functio ns o f a ho spital, including highly co mplicated mechanical, electrical, and teleco mmunicatio ns systems, requires specialized kno wledge and expertise. No o ne perso n can reaso nably have co mplete kno wledge, which is why specialized co nsultants play an impo rtant ro le in ho spital planning and design. The functio nal units within the ho spital can have co mpeting needs and prio rities. Idealized scenario s and stro ngly-held individual preferences must be balanced against mandato ry requirements, actual functio nal needs (internal traffic and relatio nship to o ther departments), and the financial status o f the o rganizatio n.

Aesthetic Opportunities Air Barrier Systems in Buildings Air Decontamination VIEW ALL RELAT ED (4 3) VIEW RESO URCE PAG E INDEX

In additio n to the wide range o f services that must be acco mmo dated, ho spitals must serve and suppo rt many different users and stakeho lders. Ideally, the design pro cess inco rpo rates direct input fro m the o wner and fro m key ho spital staff early o n in the pro cess. The designer also has to be an advo cate fo r PDFmyURL.com

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the patients, visito rs, suppo rt staff, vo lunteers, and suppliers who do no t generally have direct input into the design. Go o d ho spital design integrates functio nal requirements with the human needs o f its varied users.

The basic fo rm o f a ho spital is, ideally, based o n its functio ns:

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bed-related inpatient functio ns o utpatient-related functio ns diagno stic and treatment functio ns administrative functio ns service functio ns (fo o d, supply) research and teaching functio ns Physical relatio nships between these functio ns determine the co nfiguratio n o f the ho spital.

Certain relatio nships between the vario us functio ns are required—as in the fo llo wing flo w diagrams.

These flo w diagrams sho w the mo vement and co mmunicatio n o f peo ple, materials, and waste. Thus the physical co nfiguratio n o f a ho spital and its transpo rtatio n and lo gistic systems are inextricably intertwined. The transpo rtatio n systems are influenced by the building co nfiguratio n, and the co nfiguratio n is heavily dependent o n the transpo rtatio n systems. The ho spital co nfiguratio n is also influenced by site restraints and o ppo rtunities, climate, surro unding facilities, budget, and available techno lo gy. New alternatives

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available techno lo gy. New alternatives are generated by new medical needs and new techno lo gy.

In a large ho spital, the fo rm o f the typical nursing unit, since it may be repeated many times, is a principal element o f the o verall co nfiguratio n. Nursing units to day tend to be mo re co mpact shapes than the elo ngated rectangles o f the past.

Co mpact rectangles, mo dified triangles, o r even circles have been used in an attempt to sho rten the distance between the nurse statio n and the patient's bed.

The cho sen so lutio n is heavily dependent o n pro gram issues such as o rganizatio n o f the nursing pro gram, number o f beds to a nursing unit, and number o f beds to a patient ro o m. (The trend, recently reinfo rced by HIPAA, is to all private ro o ms.)

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BUILDING AT T RIBUT ES Regardless o f their lo catio n, size, o r budget, all ho spitals sho uld have certain co mmo n attributes.

Ef f iciency and Cost - Ef f ect iveness An efficient ho spital layo ut sho uld: Pro mo te staff efficiency by minimizing distance o f necessary travel between frequently used spaces Allo w easy visual supervisio n o f patients by limited staff Include all needed spaces, but no redundant o nes. This requires careful pre-design pro gramming.

Pro vide an efficient lo gistics system, which might include elevato rs, pneumatic tubes, bo x co nveyo rs, manual o r auto mated carts, and gravity o r pneumatic chutes, fo r the efficient handling o f fo o d and clean supplies and the remo val o f waste, recyclables, and so iled material Make efficient use o f space by lo cating suppo rt spaces so that they may be shared by adjacent functio nal areas, and by making prudent use o f multi-purpo se spaces Co nso lidate o utpatient functio ns fo r mo re efficient o peratio n—o n first flo o r, if po ssible—fo r PDFmyURL.com

direct access by o utpatients Gro up o r co mbine functio nal areas with similar system requirements Pro vide o ptimal functio nal adjacencies, such as lo cating the surgical intensive care unit adjacent to the o perating suite. These adjacencies sho uld be based o n a detailed functio nal pro gram which describes the ho spital's intended o peratio ns fro m the standpo int o f patients, staff, and supplies.

Flexibilit y and Expandabilit y Since medical needs and mo des o f treatment will co ntinue to change, ho spitals sho uld: Fo llo w mo dular co ncepts o f space planning and layo ut Use generic ro o m sizes and plans as much as po ssible, rather than highly specific o nes Be served by mo dular, easily accessed, and easily mo dified mechanical and electrical systems Where size and pro gram allo w, be designed o n a mo dular system basis, such as the VA Ho spital Building System . This system also uses walk-thro ugh interstitial space between o ccupied flo o rs fo r mechanical, electrical, and plumbing distributio n. Fo r large pro jects, this pro vides co ntinuing adaptability to changing pro grams and needs, with no firstVAMC Albuquerque, NM co st premium, if pro perly planned, designed, and bid. The VA Ho spital Building System also allo ws vertical expansio n witho ut disruptio ns to flo o rs belo w.

Be o pen-ended, with well planned directio ns fo r future expansio n; fo r instance po sitio ning "so ft spaces" such as administrative departments, adjacent to "hard spaces" such as clinical labo rato ries.

Therapeut ic Environment Ho spital patients are o ften fearful and co nfused and these

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Ho spital patients are o ften fearful and co nfused and these feelings may impede reco very. Every effo rt sho uld be made to make the ho spital stay as unthreatening, co mfo rtable, and stress-free as po ssible. The interio r designer plays a majo r ro le in this effo rt to create a therapeutic enviro nment . A ho spital's interio r design sho uld be based o n a co mprehensive understanding o f the facility's missio n and its patient pro file. The characteristics o f the patient pro file will determine the degree to which the interio r design sho uld address aging, lo ss o f visual acuity, o ther physical and mental disabilities, and abusiveness. (See VA Interio r Design Manual .) So me impo rtant aspects o f creating a therapeutic interio r are: Using familiar and culturally relevant materials wherever co nsistent with sanitatio n and o ther functio nal needs Using cheerful and varied co lo rs and textures, keeping in mind that so me co lo rs are inappro priate and can interfere with pro vider assessments o f patients' pallo r and skin to nes, diso rient o lder o r impaired patients, o r agitate patients and staff, particularly so me psychiatric patients .

Admitting ample natural light wherever feasible and using co lo r-co rrected lighting in interio r spaces which clo sely appro ximates natural daylight Pro viding views o f the o utdo o rs fro m every patient bed, and elsewhere wherever po ssible; pho to murals o f nature scenes are helpful where o utdo o r views are no t available Designing a "way-finding" pro cess into every pro ject. Patients, visito rs, and staff all need to kno w where they are, what their destinatio n is, and ho w to get there and return. A patient's sense o f co mpetence is enco uraged by making spaces easy to find, identify, and use witho ut asking fo r help. Building elements, co lo r, texture, and pattern sho uld all give cues, as well as artwo rk and signage. (As an example, see VA Signage Design Guide. ) Fo r an in-depth view see WBDG—Therapeutic Enviro nments .

Cleanliness and Sanit at ion Ho spitals must be easy to clean and maintain. This is facilitated by: Appro priate, durable finishes fo r each functio nal space Careful detailing o f such features as do o rframes, casewo rk, and finish transitio ns to avo id dirt-catching and hard-to -clean crevices and jo ints Adequate and appro priately lo cated

Cross- section showing interstitial space with deck above an occupied floor PDFmyURL.com

above an occupied floor

ho usekeeping spaces Special materials, finishes, and details fo r spaces which are to be kept sterile, such as integral co ve base. The new antimicro bial surfaces might be co nsidered fo r appro priate lo catio ns.

Inco rpo rating O&M practices that stress indo o r enviro nmental quality ( IEQ)

Accessibilit y All areas, bo th inside and o ut, sho uld: Co mply with the minimum requirements o f the Americans with Disability Act ( ADA) and, if federally funded o r o wned, the Unifo rm Federal Accessibility Standards (UFAS) In additio n to meeting minimum requirements o f ADA and/o r UFAS, be designed so as to be easy to use by the many patients with tempo rary o r permanent handicaps Ensuring grades are flat eno ugh to allo w easy mo vement and sidewalks and co rrido rs are wide eno ugh fo r two wheelchairs to pass easily Ensuring entrance areas are designed to acco mmo date patients with slo wer adaptatio n rates to dark and light; marking glass walls and do o rs to make their presence o bvio us

Cont rolled Circulat ion A ho spital is a co mplex system o f interrelated functio ns requiring co nstant mo vement o f peo ple and go o ds. Much o f this circulatio n sho uld be co ntro lled.

Outpatients visiting diagno stic and treatment areas sho uld no t travel thro ugh inpatient functio nal areas no r enco unter severely ill inpatients Typical o utpatient ro utes sho uld be simple and clearly defined Visito rs sho uld have a simple and direct ro ute to each patient nursing unit witho ut penetrating o ther functio nal areas Separate patients and visito rs fro m industrial/lo gistical areas o r flo o rs Outflo w o f trash, recyclables, and so iled materials sho uld be separated fro m mo vement o f fo o d and clean supplies, and bo th sho uld be separated fro m ro utes o f patients and visito rs Transfer o f cadavers to and fro m the mo rgue sho uld be o ut o f the sight o f patients and visito rs Dedicated service elevato rs fo r deliveries, fo o d and building maintenance services

Aest het ics Aesthetics is clo sely related to creating a therapeutic enviro nment (ho melike, attractive.) It is impo rtant in enhancing the ho spital's public image and is thus an impo rtant marketing to o l. A better enviro nment also co ntributes to better staff mo rale and patient care. Aesthetic co nsideratio ns include: Increased use o f natural light, natural materials, and textures Use o f artwo rk Attentio n to pro po rtio ns, co lo r, scale, and detail Bright, o pen, genero usly-scaled public spaces PDFmyURL.com

Ho melike and intimate scale in patient ro o ms, day ro o ms, co nsultatio n ro o ms, and o ffices Co mpatibility o f exterio r design with its physical surro undings

Securit y and Saf et y In additio n to the general safety co ncerns o f all buildings, ho spitals have several particular security co ncerns: Pro tectio n o f ho spital pro perty and assets, including drugs Pro tectio n o f patients, including incapacitated patients, and staff Safe co ntro l o f vio lent o r unstable patients Vulnerability to damage fro m terro rism because o f pro ximity to high-vulnerability targets, o r because they may be highly visible public buildings with an impo rtant ro le in the public health system.

Sust ainabilit y Ho spitals are large public buildings that have a significant impact o n the enviro nment and eco no my o f the surro unding co mmunity. They are heavy users o f energy and water and pro duce large amo unts o f waste. Because ho spitals place such demands o n co mmunity reso urces they are natural candidates fo r sustainable design.

Sectio n 1.2 o f VA's HVAC Design Manual is a go o d example o f health care facility energy co nservatio n standards that meet EPAct 20 0 5 (PDF 1.3 MB, 550 p g s ) and Executive Order 13423 requirements. The Energy Independence and Security Act o f 20 0 7 (EISA) (PDF 740 KB, 310 p g s ) pro vides additio nal requirements fo r energy co nservatio n. Also see LEED's (Leadership in Energy and Enviro nmental Design) USGBC LEED fo r Healthcare

Relat ed Issues The HIPAA (Health Insurance Po rtability and Accessibility Act o f 19 9 6 ) regulatio ns address security and privacy o f "pro tected health info rmatio n" (PHI). These regulatio ns put emphasis o n aco ustic and visual privacy, and may affect lo catio n and layo ut o f wo rkstatio ns that handle medical reco rds and o ther patient info rmatio n, paper and electro nic, as well as patient acco mmo datio ns."

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EMERGING ISSUES Amo ng the many new develo pments and trends influencing ho spital design are: The decreasing numbers o f general practitio ners alo ng with the increased use o f emergency facilities fo r primary care The increasing intro ductio n o f highly so phisticated diagno stic and treatment techno lo gy Requirements to remain o peratio nal during and after disasters—see, fo r example, VA's Physical Security Manuals PDFmyURL.com

State laws requiring earthquake resistance, bo th in designing new buildings and retro fitting existing structures Preventative care versus sickness care; designing ho spitals as all-inclusive "wellness centers" Use o f hand-held co mputers and po rtable diagno stic equipment to allo w mo re mo bile, decentralized patient care, and a general shift to co mputerized patient info rmatio n o f all kinds. This might require co mputer alco ves and data po rts in co rrido rs o utside patient bedro o ms. Fo r mo re info rmatio n, see WBDG Integrate Techno lo gical To o ls Need to balance increasing attentio n to building security with o penness to patients and visito rs Emergence o f palliative care as a specialty in many majo r medical centers A gro wing interest in mo re ho listic, patient-centered treatment and enviro nments such as pro mo ted by Planetree. This might include pro viding mini-medical libraries and co mputer terminals so patients can research their co nditio ns and treatments, and lo cating kitchens and dining areas o n inpatient units so family members can prepare fo o d fo r patients and families to eat to gether.

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RELEVANT CODES AND STANDARDS Ho spitals are amo ng the mo st regulated o f all building types. Like o ther buildings, they must fo llo w the lo cal and/o r state general building co des. Ho wever, federal facilities o n federal pro perty generally need no t co mply with state and lo cal co des, but fo llo w federal regulatio ns. To be licensed by the state, design must co mply with the individual state licensing regulatio ns. Many states ado pt the FGI Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed belo w as a reso urce, and thus that vo lume o ften has regulato ry status.

State and lo cal building co des are based o n the mo del Internatio nal Building Co de (IBC). Federal agencies are usually in co mpliance with the IBC except NFPA 10 1 (Life Safety Co de), NFPA 70 (Natio nal Electric Co de), and Architectural Barriers Act Accessibility Guidelines (ABAAG) o r Unifo rm Federal Accessibility Standards (UFAS) takes precedence."

Since ho spitals treat patients who are reimbursed under Medicare, they must also meet federal standards, and to be accredited, they must meet standards o f the Jo int Co mmissio n o n the Accreditatio n o f Healthcare Organizatio ns (JCAHO). Generally, the federal go vernment and JCAHO refer to the Natio nal Fire Pro tectio n Asso ciatio n (NFPA) mo del fire co des, including Standards fo r Health Care Facilities (NFPA 9 9 ) and the Life Safety Co de (NFPA 10 1).

The American with Disabilities Act ( ADA) applies to all public facilities and greatly the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG) o r the Unifo rm Federal Accessibility Standards (UFAS) apply to federal and federally funded facilities. The technical requirements do no t differ greatly fro m the ADA requirements. See WBDG Accessible Regulatio ns o f the Occupatio nal Safety and Health Administratio n ( OSHA) also affect the design PDFmyURL.com

o f ho spitals, particularly in labo rato ry areas.

Federal agencies that build and o perate ho spitals have develo ped detailed standards fo r the pro gramming, design, and co nstructio n o f their facilities. Many o f these standards are applicable to the design o f no n-go vernmental facilities as well. Amo ng them are: Department o f Veterans Affairs (VA), Office o f Co nstructio n & Facilities Management Technical Info rmatio n Library co ntains many guides and standards, including: Design Guides fo r planning many different departments and clinics, design manuals o f technical requirements, equipment lists, master specificatio ns, ro o m finishes, space planning criteria, and standard details.

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MAJOR RESOURCES WBDG Federal Mandate Executive Order 13423 Technical Guidance Products and Systems Building Envelo pe Design Guide

Websit es See WBDG Health Care Facilities fo r generic health care facilities websites

Publicat ions Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibro ck and Debra Harris. New Yo rk: Jo hn Wiley & So ns, Inc., 20 11.—Inno vative design so lutio ns in key areas such as lighting, aco ustics, co lo r, and finishes Design Guide fo r Impro ving Ho spital Safety in Earthquakes, Flo o ds, and High Winds: Pro viding Pro tectio n to Peo ple and Buildings. FEMA, 20 0 7.

Development Study—VA Hospital Building System by Building Systems Develo pment and Sto ne, Marraccini & Patterso n. Washingto n, DC: U.S. Go vernment Printing Office, rev. 19 77.

Emergency Department Design: A Practical Guide to Planning for the Future by Jo hn Huddy and Michael T. Rapp. Irving, Texas: ACEP (American Co llege o f Emergency Physicians) 20 0 0 .

Healthcare Facility Planning: Thinking Strategically by Cynthia Hayward, AIA, FAAHC, ACHA. Health Administration Press and the American College of Healthcare Executives, 2005.

Hospitals, The Planning and Design Process , 2nd ed. by Owen B. Hardy and Lawrence P. Lammers. Ro ckville, Md.: Aspen Publishers, 19 9 6 .

Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations PDFmyURL.com

by Jain Malkin. New Yo rk: Jo hn Wiley & So ns, Inc., 19 9 2.

Healthcare Design—A quarterly magazine with design articles and presentatio ns o f recent pro jects Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition , by Jain Malkin. New Yo rk: Jo hn Wiley & So ns, Inc., 20 0 2.

UFC 4-510-01 Design: Medical Military Facilities See WBDG Health Care Facilities fo r generic health care facilities publicatio ns

Tools SpaceMedGuide-A Space Planning Guide fo r Healthcare Facilities —a po pular planning to o l pro viding state-o f-the-art planning metho do lo gies, industry benchmarks, and planning tips.

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