Hospitals - A Design Manual by Birkhäuser

A Design Manual

Hospitals Cor Wagenaar Noor Mens Guru Manja Colette Niemeijer Tom Guthknecht

COR WAGENAAR, NOOR MENS

The Unfallkrankenhaus, Berlin, Germany, Karl Schmücker und Partner, 1997, is the result of the reconstruction and extension of a historical pavilion hospital. It fits into its surroundings rather than dwarfing it, adding a friendly dimension often lacking in older facilities.

view that people are ill, and therefore in need of medical treatment, if from an objective, scientific point of view one or more ‘mechanical’ failures and dysfunctional parts can be identified (which is almost always the case). Political and economic trends, not public pressure, are decisive for this paradigm shift. In an effort to control public health expenditures, many countries in Western Europe are moving away from healthcare systems in which the volume and the costs of medical treatment are determined by state bureaucracies. The trend toward transferring responsibility to the ‘end user’ is affecting all aspects of the economy, and there is little doubt that it will also transform medicine. Ideally, the individual customers should have a say in the cost and the quality of the services they are being offered; patients should use their purchasing power to force providers to adjust their services to the needs of the patients. The paradigm change obliges patients to better understand the options open to them; they have to be free to select the hospital or medical specialist of their preference, and they need to understand that they share responsibility for all decisions concerning their health and treatment. In order for patients to make rational choices, data such as the effectiveness, quality and costs of different therapies, the track record of medical specialists and the performance of hospitals have to be transparent and freely available. However, most countries still have a long way to go before this is the case. Technology, especially the Internet, plays a fundamental role in this paradigm shift. If the unprecedented abundance of information now readily available can be properly managed, information technology may help to create the ‘expert’ patient. ‘By increasing the likelihood of preventions over cure’, Sunand Prasad, a British hospital expert, believes, ‘such a patient will reduce expenditure in the health system’. In his words: ‘The costs of creating the expert patient must be far less than the costs of treatment of preventable diseases.’15 The way the Internet facilitates communication between the medical establishment and the patients helps to further reduce the gap between the two groups. Instead of obliging patients to visit the doctor, certain procedures — from diagnosis to monitoring and follow-up — can be organized through websites or apps. Why, then, is it taking so long for this paradigm change to take hold more broadly than it has to date? Obviously, resistance from the medical world continues to a certain degree. Many patients are reluctant to take on any responsibility for their treatment and prefer to surrender all initiative to the medical authorities. The substantial costs involved in public health also tend to foster conservatism: ‘The great expense of hospitals, together with their complexity and user requirements, militates against change. Should something that is untried be planned and built?’, Lawrence Nield wonders.16 Despite all this, the momentum for change appears to be irreversible. If the necessary conditions are met — if the patient is well-informed, if the effectiveness of treatments and performance of providers is transparent and, ideally, if a network of medical and non-medical facilities is in place — the shift of responsibility to the patient is bound to enhance rather than diminish the quality of healthcare. This empowerment will transform the medical machine into a service provider that takes its clients seriously.

Healthcare as a Public Service A Design Manual

Hospitals Cor Wagenaar Noor Mens Guru Manja Colette Niemeijer Tom Guthknecht Contributions by Giuseppe Lacanna Peter Luscuere

Domenico di Bartolo, Cura e governo degli infermi (Cure of the sick), fresco in the Santa Maria della Scala, Sala del Pellegrinaio, Siena, Italy, (from the Episodes from the Life of Blessed Sorore), 1440–1441.

In the Middle Ages, hospitals were established as social institutions and remained so for centuries. They were public facilities inasmuch as they addressed a public issue: care of the poor who fell ill, providing food, shelter and succor, though hardly any treatment in the modern sense. Unless charity institutions intervened, the poor would live out their lives in misery, especially if illness prevented them from earning a living. In striking contrast with the poverty of their inhabitants, hospital buildings soon developed into wealthy, representative landmarks. Often, their sponsors endowed them with paintings, sculptures and lavishly decorated rooms for the people who managed them. Some hospitals even became patrons of the arts.17 Still, even the best endowed hospitals remained almshouses, offering no therapies that could not be found elsewhere. It was only in the late 19th century that they developed into institutions providing the best medical care available, mainly because of the introduction of Röntgen’s X-ray machine in 1897 that required patients to come to them for treatment. Whereas until then the well-to-do avoided hospitalization at all costs, they now had no alternatives. The cost of hospital treatment began to rise, and though charity often remained a valuable source of income for hospitals, patients frequently had to pay for their care. Since the poor could not afford these costs, hospitals temporarily lost their public function, a situation which prevailed in most countries until the introduction of public health systems. It can be argued that ‘hospitals fit many of the criteria of a public good. There are benefits for society from a socially cohesive, healthier and more productive population.’18 Public healthcare systems are usually either run by the state (the Bevan model) or organized within a state-controlled framework based on health insurance policies (the Bismarck model). Why did public authorities enter this field? With the exception of semi-

Birkhäuser Basel

DEFINING THE HOSPITAL OF TOMORROW

Paradigm Change? The Perspective of the Patient

We would like to thank the organizers of the ‘Building the Future of Health’ conference, www.btfoh.eu, for their kind support of this COR WAGENAAR, NOOR MENS publication.

Taking care of patients has always been the core business of hospitals, but as the ‘Short History of Hospital Architecture’ in this book demonstrates, this does not mean that they Layout and cover design Jenna Gesse, Berlin were built with the intention to cure people. That only became their primary mission with the advent of the scientific revolution of the 17th and 18th centuries, when the medical proGraphic design concept of ‘Design Manual’ series fession began to look more toward empirical science for inspiration. This change marks Oliver Kleinschmidt, Berlin the beginning of an unending struggle against irrational views about illness and healing. There has never been a shortage of rituals, rites and the use of herbs and drugs, the alleged Cover Akershus University Hospital, Oslo, C. F. Møller Architects; photo: Torben Ekserod healing qualities of which often depended entirely on religious beliefs, superstition or salesmanship. The medical profession has made the fight against these dubious therapies Frontispiece Surgical Clinic La Croix-Rousse, Lyon, one of its primary objectives and hospitals as we know them today are the physical manifesAtelier Christian de Portzamparc; photo: Erick Saillet tation of this fight. Since the late 18th century, they could be called ‘healing machines’ (machine à guérir), that is to say, buildings designed to cure those suffering from medical disConcept Cor Wagenaar, Noor Mens orders. A machine is a technological device designed according to rational principles and Project texts Noor Mens, Cor Wagenaar because hospitals have defined themselves as machines run by medical professionals and technicians, they have always been seen as offering the best possible chance of recovery. Copy-editor Harvey L. Mendelsohn, Cambridge, The negative aspect of this outlook is that people were treated as objects of the same Massachusetts order as any other objects studied by the natural sciences. For centuries, medical professionals adhered to the Cartesian distinction between mind and body, seeing the latter as Editorial supervision Ria Stein, Berlin René Descartes (1596–1650). Portrait by Jan an object which functioned solely according to physical laws (and which was thus divorced Baptist Weenix. is associated the Production KatjaDescartes Jaeger, Amelie Solbrig,with Berlin from the workings of the mind). Diseases, therefore, had to be dealt with in much the same conviction that mind and body represent sepaway as defective machines: by interventions based on the findings of the natural sciences. rate worlds, implying that people’s state GmbH, of mindBerlin Lithography bildpunkt Druckvorstufen Medicine considered itself as one of them and thus treated mental illness, too, in the same cannot impact on150 their medical condition in Paper BVS matt, g/m² way, i.e. as a mechanical failure. any way. Medialis Offsetdruck GmbH, Berlin Printing As long as the Cartesian separation between mind and body prevailed, the idea of taking into account the patients’ personal experiences was believed to be on a par with the Library of Congress Cataloging-in-Publication data superstitious concepts medicine had tried so hard to overcome. Ultimately, the emergence A CIP catalog record for this book has been applied for of at psychology at the end of the 19th century began to undermine the Cartesian dichotomy, the Library of Congress. and since then it has become widely accepted that people’s mental states can have an impact on their physical well-being. Psychology, however, did not at first reject the view that Bibliographic information published by the German National mental disorders should be seen as mechanical failures. Moreover, the idea that patients Library. The German National Library lists this publication should have a say in what is done to their bodies and minds — something which is now in the Deutsche Nationalbibliografie; detailed bibliographic data are available on the Internet at http://dnb.ddb.de.believed to reduce the stress on them — had not yet developed. In the 1930s, people’s personal experiences were increasingly seen as linked to their This work is subject to copyright. All rights are reserved, social and physical environment. Consequently, health-oriented interventions in the enviwhether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuseronment, previously focused on hygiene, now incorporated attempts to offer relief from of illustrations, recitation, broadcasting, reproductionstress. In the 1950s and 1960s, the modern housing estates that were then being built in large numbers came under fire, with experts blaming the living environment they providon microfilms or in other ways, and storage in databases. For any kind of use, permission of the copyright owner ed for a great increase in psychological diseases associated with stress. Similarly, hospitals must be obtained. themselves began to be seen as stressful environments that hampered their patients’ healing processes. Friendlier, less machine-like architecture was promoted as a way to diminish This book is also available as an e-book stress, and patient-centered care became a popular slogan. Moreover, new organizational (ISBN PDF 978-3-0356-1125-0; ISBN EPUB 978-3-0356-1126-7). concepts were developed to alleviate the inevitable tension people experience when they are hospitalized. In the same vein, the evidence-based design movement that emerged in © 2018 Birkhäuser Verlag GmbH, Basel the United States in the 1980s began to explore the ways people react to their physical and P.O. Box 44, 4009 Basel, Switzerland social environment with the aim of learning how spatial design can influence medical outPart of Walter de Gruyter GmbH, Berlin/Boston comes. In sum, psychology was perceived as a way of exploring the link between personal experiences and objectively verifiable medical data. Printed on acid-free paper produced from For quite some time, a paradigm shift has been underway that takes this evolution chlorine-free pulp. TCF ∞ one step further, inviting patients to take an active role in treatment, something that in the Printed in Germany United States is already considered a matter of ‘conventional wisdom’.11 ‘The elevation of ISBN 978-3-03821-473-1 the patient to partner’, the American Joint Commission concluded, ‘is not a ceremonial ti987654321 tle bestowed for a “feel good” moment, but has significant implications for the quality and www.birkhauser.com safety of patient care’.12 From the traditional, medical point of view, this turns the world 12

DEFINING THE HOSPITAL OF TOMORROW

Principles of the Hospital Building 8 Preface Cor Wagenaar, Noor Mens 9 Introduction Cor Wagenaar, Noor Mens

DEFINING THE HOSPITAL OF TOMORROW

DESIGNING HOSPITALS

PUBLIC SPACES

TREATMENT AREAS

12 Paradigm Change? The Perspective of the Patient Cor Wagenaar, Noor Mens

23 Distribution of Healthcare Facilities: Centralization, Decentralization and the Network Hospital Guru Manja, Colette Niemeijer, Cor Wagenaar

52 Zoning and Traffic System Tom Guthknecht, Peter Luscuere, Guru Manja, Colette Niemeijer, Cor Wagenaar

67 Planning: an Integral Approach Tom Guthknecht

15 Healthcare as a Public Service Cor Wagenaar, Noor Mens 19 The Business Case for Hospitals Guru Manja, Colette Niemeijer 22 Changing Healthcare Needs Cor Wagenaar, Noor Mens

27 The Design of Hospitals: Care Pathways Guru Manja, Colette Niemeijer, Cor Wagenaar 32 Processes and Spaces: the Example of the Maternity Department Guru Manja, Colette Niemeijer, Cor Wagenaar

58 Arrival and Entrance Noor Mens

69 Outpatient Department Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar

61 Public Spaces in and Around the Hospital: Streets, Squares, Patios, Waiting Areas, Healing Gardens Giuseppe Lacanna, Cor Wagenaar

75 Inpatient Wards Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar

65 Wayfinding: Signage and Orientation Systems Noor Mens

83 Diagnostic Imaging Tom Guthknecht, Guru Manja, Cor Wagenaar

37 85 Evidence-Based Design for Operating Theater and Healing Environments Recovery Area and expertise — Cor Wagenaar The Bijlmermeer, Amsterdam, the Netherlands, upside down, offering people who obviously lack professional knowledge 1968–1975. The ‘Cartesian Dichotomy’ was inTom Guthknecht, Guru and are likely to be burdened with numerous unsubstantiated notions — the opportunity creasingly challenged in the 20th century. Manja, Colette Niemeijer, 42In the to interfere with medical procedures they know nothing about. Giving patients a say in the 1950s, the phenomenon of stress was discussed Wagenaar The Building Type way theyand are treated clearly touches upon the very essence Cor of medical practice and remains at numerous medical conferences and linked its Emergence quite difficult to achieve. ‘In ideal circumstances, hospitals would be highly responsive to to mental and physical health problems. New 100 are in a weak position. They Noor housing estates like the Bijlmermeer were seenMens the needs of their patients. In reality, this is rarely so. Patients as particularly unhealthy. Intensive are in an unfamiliar setting, vulnerable because of their illness and Care their Unit lack of informaGuthknecht, tion and dependent on others’, Martin McKee and JudithTom Healy conclude Guru in a report of Manja, Colette the Joint Commission, a not-for-profit organization that assesses health Niemeijer, programs and orCor Wagenaar ganizations in the United States.13 ‘Although it is self-evident that care should be focused on the needs of the patient, in reality many hospitals are run more for the convenience of 108 as an impersonal ‘healing the staff.’14 Obviously, it is very difficult to reconcile the hospital machine’ with the hospital as a caring institution that notEmergency only offersDepartment treatment, comfort and support, but also invites patients to take responsibility.Tom Guthknecht, Guru Manja, Colette Niemeijer, This paradigm shift coincides with a new definition on health, one that is widely proCor Wagenaar moted by the World Health Organization: people can consider themselves healthy if they can do anything they want without being hampered by their physical or mental conditions. 111 and breaks away from the Clearly, this approach puts personal experiences at the center Laboratory Department Tom Guthknecht 13

Selection of Projects GENERAL HOSPITALS

118 Circle Bath Bath, UK Foster + Partners

140 Hôpital Riviera-Chablais Rennaz, Switzerland Groupe-6; GD architectes

142 122 Medisch Spectrum Twente Butaro New North District ZealandHospital Hospital, Hillerød near Copenhagen, Denmark, Herzog & de Meuron, Enschede, the Netherlands Butaro, Rwanda 2014. A serpentine band of two stories surrounds IAA Architecten MASS Design Group a large central garden on top of two layers. The roof on which the central garden sits is pierced 124 by numerous lightwells that provide the148 outRey Juan Carlos Hospital Private Hospital and the hot floor with patient department ample daylight. Madrid, Spain Villeneuve d’Ascq

Lille, France Jean-Philippe Pargade Architectes 128 Extension Kolding Hospital Kolding, Denmark Schmidt Hammer Lassen Architects 130 AZ Groeninge Kortrijk, Belgium Baumschlager Eberle Architekten 134 Zaans Medisch Centrum Zaandam, the Netherlands Mecanoo

CHILDREN’S HOSPITALS

UNIVERSITY HOSPITALS

SPECIALIZED HOSPITALS

160 Nemours Children’s Hospital Orlando, Florida, USA Stanley Beaman & Sears

188 Center for Surgical Medicine University Hospital Düsseldorf Düsseldorf, Germany Heinle, Wischer und Partner

210 Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, Nevada, USA Frank Gehry

164 Randall Children’s Hospital at Legacy Emanuel Portland, Oregon, USA ZGF Architects

192 St. Olav’s Hospital Trondheim, Norway Nordic – Office of Architecture; Ratio Arkitekter

168 Juliana Children’s Hospital Rafael de La-Hoz The Hague, the Netherlands and treatment are no longer their main activities; instead,196 they focus on eradicating and 5 University Hospital MVSA preventing diseases’. One areaArchitects that appears to be leadingAkershus the way here is preparation for 152 Oslo, notably Norway England, these are parenthood, including classes in relaxation; in some countries, Meander Medisch C.goal, F. Møller Architects 172 already Centrum offered in community health centers.6 To reach this the barriers between proAmersfoort,fessional the Netherlands and disease prevention and health promotion will medicine andMother-Child services providing Atelier PROhave architekten Surgicalwill Center to disappear and hospitals need to accommodate200 the latter.7 Instead of remaining Reconstruction of the Kaiser-Franz-Josef-Spital isolated organizations that only cover a part of the health continuum, they need toJohann become 156 Goethe University Vienna, Austria aware of their social responsibility and play their part in Wolfgang renegotiating the sharing of reCleveland Clinic Abu Dhabi Hospital Nickl & Partner Architektencan facilitate sponsibilities within this continuum. Architecture this change of direction by Abu Dhabi, promoting the “re-urbanization” of the hospital. Frankfurt am Main, Germany United Arab Emirates Nickl &primary Partner concern, Architekten 176 is all about statistics, the hospital’s Whereas public health we conHDR Annthe & Robert H.perspective Lurie tend, should be to consider patients’ — the personal experiences of the peoChildren’s Hospital ple it has been designed to help. Health problems remind204 us of our mortality and of the Erasmus MC Hospital and Chicago, Illinois, USA fragility of our well-being. Confronting a disease is always a highly personal and stressEducation Center ZGFinvolvement Architects in our personal affairs ful matter, and a hospital’s can make us uncomfortable. Rotterdam, the Netherlands Therefore, hospitals should be designed to reduce stress and put patients at ease, and manEGM architects; KAAN 182 care with a human touch. aged in a way that provides Royal Children’s Hospital The structure of this publication follows from theseArchitecten recent developments: the first Melbourne, Australia introduces a fundamental paradigm change: part, ‘Defining the Hospitals of Tomorrow’, Leecethat Partnership; the transition to a way Billard of thinking puts the ‘end user’, in this case the patient, at the Bates center of attention. This shiftSmart exceeds the ambitions of the older models of ‘patient-centered care’. Now, by making use of the latest innovations in information technology, the Internet and related devices, patients are able to become actively involved in monitoring and even controlling their own therapies. Moreover, they should be able to make choices for themselves: what are the best options for treating a condition? Which hospital has had the most success with the chosen treatment? What are the consequences of a specific procedure for one’s quality of life? Ideally, the range of alternatives would be clear and the past performance of all medical institutions transparent. Having outlined this new perspective, we continue with texts that focus on the implications of the public nature of healthcare, thus placing medicine within the broader spectrum of policies aimed at promoting public health. Obviously, making these changes affordable over the long term involves the financial aspects of running a hospital, which is the next issue we address. Finally, we conclude with ‘Changing Healthcare Needs’ on how demographic trends and the effects of globalization are likely to change the needs hospitals will have to meet. The second part, ‘Designing Hospitals’, introduces three phenomena that are increasingly influencing hospital architecture: new views on the optimal distribution of healthcare facilities (for instance, a concentration in large building complexes or a network of smaller facilities), the concept of care pathways and evidence-based design. A care pathway encom-

212 Surgical Clinic La Croix-Rousse Lyon, France Atelier Christian de Portzamparc 216 Milstein Family Heart Center NewYork-Presbyterian Hospital New York, New York, USA Pei Cobb Freed & Partners 220 National Center for Tumor Diseases Heidelberg, Germany Behnisch Architekten 224 Institut Imagine Paris, France Ateliers Jean Nouvel; Valero Gadan Architectes 228 Cancer Centre at Guy’s London, UK Rogers Stirk Harbour + Partners

APPENDIX REHABILITATION OUTPATIENT CLINICS AND SUPPORT AND HEALTH CENTERS passes the series of interactions betweenCLINICS a patient with a specific medical condition and healthcare providers, from the initial appointment for diagnosis to the moment medical 248Only portions of this trajectory 268 232 care is no longer needed. are located in a hospital setting The Care Authors Maggie’s West London Ruukki Health (the Clinic first appointment is usually Centre with a general practitioner). pathways may include Ruukki, Finland visits to therapists whoLondon, work at UK home or in small clinics, nursing staff who may assist pa268of medical treatment around Rogers Stirk Harbour + Partners alt Arkkitehdit; Architecture tients at home and in rehabilitation clinics. The organization Index of Places Office Karsikas care pathways that ideally are monitored by the patients themselves — relying, among oth250and related devices — will change the way hospital services are er things, on the Internet 270 the spatial consequences Maggie’s Centresuite Gartnavel 234 distributed. The example of the delivery is used to illustrate Index of Names Glasgow,principles UK Municipal Healthcare of the choice of organizational adopted, highlighting a way of thinking that is OMA Centers Sanrelevant Blas, to all aspects of hospital architecture. The growing body of research in the field Usera, Villaverde of evidence-based design, which uses scientific expertise 271 to inform design solutions, has Illustration Credits 252 on the way hospitals are planned. Madrid, Spain begun to have an influence The second part of the book Gheskio Cholera Estudio Entresitio concludes with a historical overview showing that the profound changes we witness today Centerin the past. have been preceded by Treatment similar transitions Port-au-Prince, Haiti 238 In the third and fourth part we enter the hospital itself, presenting it as a composition MASS Design UCLA Outpatient Surgery defined of the functionally units that Group make up a general hospital (excluding, however, the and Medicalpsychiatric Office Building wards). While discussing these components, we touch on a number of recur254 Santa Monica, California, USA ring themes concerning the contribution of each department to the patient care pathway. Counseling Center Michael W. What Folonis is Architects the objective ofCancer the procedures carried out in this department? Which areas of exLivsrum, Denmark pertise and what type of information does it draw on? What is the expected interaction Arkitekter 240 with the patient? WhatEFFEKT is the usual condition of the patient being treated in this departNew QEII Hospital ment? How seriously does the disease — or the intervention — affect, for instance, his or Welwyn Garden City, UK degree of 258 her mobility, consciousness and emotional state? What equipment is involved? Center Penoyre & Prasad If the treatment carriedHealthcare out in this department is part of a care pathway, what precedes it for Cancer Patients and what follows it? Then, we survey different design options. The third part, ‘Public SpacDenmark 242 es’, focuses on the areasCopenhagen, of the institution that are open to all users, including visitors and Nord Architects Outpatientpeople Clinic living in the neighborhood. Public spaces include the entrance, halls, patios and the Hospital-Asilo Granollers mainoftraffic infrastructure, both indoors and outdoors. The fourth part takes us to the treatGranollers, Spain ment areas. Portions of262 the latter are open to the public; in other parts, where the interacRehabilitation Pinearq tion between medical professionals andCenter patients takes place, visitors are not allowed. Klimmendaal Finally, a carefullyGroot curated selection of case studies documents general hospitals, Arnhem,hospitals, the Netherlands children’s hospitals, university specialized hospitals, community hospitals and rehabilitation clinics. Koen van Velsen Architects Our approach conceives the hospital as a pattern of organized relationships, both internally and in the way266 it interacts with its environment, i.e. a ‘systems perspective’.8 We Anti-Aging Liferequiring an open mind and a readiness to wander regard hospital architecture as a field outside the traditional Center ways ofChaum thinking about architectural design and its boundaries. Southa Korea Hospital architecture isSeoul, no longer discipline monopolized by a handful of firms that conKMD Architects skills in an effort to protect their territory against stantly stress their unique professional invasion from outsiders. It remains, however, a domain that requires intense involvement. ‘Architects will be called in on planning processes earlier, they will be asked to contribute a very broad range of expertise and they will be active during the entire lifespan of the building. In this sense, architects will serve as caregivers, practitioners of medicine and members of the patient care team’.9 Philip Meuser even urges hospital architects to think of themselves as science fiction authors.10 They must envisage future possibilities that promise to increase the performance of public health systems and their networks of buildings. This manual aspires to help them find their way in this rapidly evolving and important field.

Selection of Projects GENERAL HOSPITALS

118 Circle Bath Bath, UK Foster + Partners

140 Hôpital Riviera-Chablais Rennaz, Switzerland Groupe-6; GD architectes

CHILDREN’S HOSPITALS

UNIVERSITY HOSPITALS

SPECIALIZED HOSPITALS

160 Nemours Children’s Hospital Orlando, Florida, USA Stanley Beaman & Sears

188 Center for Surgical Medicine University Hospital Düsseldorf Düsseldorf, Germany Heinle, Wischer und Partner

210 Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, Nevada, USA Frank Gehry

164 Randall Children’s Hospital at Legacy Emanuel Portland, Oregon, USA ZGF Architects

192 St. Olav’s Hospital Trondheim, Norway Nordic – Office of Architecture; Ratio Arkitekter

TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Intensive Care Unit Intensive care unit (ICU) design is a relatively new subject. While some of the other departments, such as the wards and facility services like laundry, have a tradition reaching back to the pavilion hospitals of the 18th century and even earlier, the intensive care unit emerged only in the second half of the 20th century. The first ICU was established 1953 in Copenhagen, Denmark in response to a polio epidemic, and the idea was subsequently adopted in the United States. However, it took some time, until the 1970s, before this innovation became more broadly accepted internationally. The initial focus of the ICU was the treatment of cardiac problems, because of the high morbidity and mortality associated with myocardial infarctions. Later on it was found that the survival rate of polytrauma patients and the treatment of multi-organ failures could be improved in the ICUs, thanks to artificial ventilation, better fluid management, and more specific medication. Intensive care will remain an area of continuous technological change in the future, with the introduction of new and improved therapies, on the one hand, and the demographic shift toward an increasingly aged and multimorbid patient population, on the other. Intensive care units have, however, acquired a bad reputation. Since they are characterized by constant and very bright, artificial light, absence of daylight (and therefore a disruption of the circadian rhythm), and, above all, continuous high levels of noise, they are often seen as the least pleasant places in a hospital. ‘Intensive care’, a nurse who worked in one for a time noted, ‘is, at best, a temporary detour during which a patient’s instability is monitored, analyzed and corrected, but it is, at worst, a high-tech torture chamber, a taste of hell during a person’s last days on earth.’127 Equally exaggerated of course, it has been said that ICUs might satisfy the criteria for torture as defined by the Geneva Convention.128 Even though the application of evidence-based design in the ICU is ‘just in its infancy’, it can be taken as a starting point, since ‘evidence shows that the physical environment affects the physiology, psychology, and social behaviors of those who experience it’. It should also be noted that ‘pleasant surroundings for patients and staff promote increased comfort, and in some cases, improved outcomes.’129 An ICU should have efficient noise control and prevent patients from being exposed to bright light 24 hours a day: what is needed is a sense of ‘calm and balance’.130 Two aspects stand out in the effort to enhance patient experience: accommodating families in the ICU, and providing natural light with views to the outside world. Family provides social support, but it can make the staff nervous if the spaces are inadequate and crowded; thus, architectural interventions are indispensable in this regard.131 Research carried out at one particular facility ‘demonstrated that family and patient satisfaction with ICU experience increased by 6 % in the new ICU environment consisting of noise-reduced, single rooms with daylight, adapted coloring and improved family facilities.’132 Natural light ‘is essential to the well-being of patients and staff’.133 ‘Natural light is one of the most comforting and familiar things you can provide in a hospital. Windows must be a part of all effective ICU and CCU designs. The height of the windows should be low enough for an optimum view so that patients can see both the ground and the sky. The idea is to admit a maximum of natural light to allow patients contact and orientation with the outside world, but the light should be controllable for sleeping.’134 Moreover, research appears to prove ‘that the design of a new facility with increased light levels and window views may have a positive impact on staff vacancy and absenteeism. Results regarding their impact on patient pain levels and staff medical errors were inconclusive; however, the data can be used as comparators for other studies on this topic.’135 An important trend is the renewed emphasis on infection control (triggered by an increase in hospital-acquired infections). Measures to combat this risk include single-occupancy rooms in ICUs, acuity-adaptable/scalable beds (fit to accommodate critical ‘intensive care’ patients as well as ‘medium care’ patients on their way to recovery), hand-washing fixtures, hygienic management, ventilation, risk assessment, safe use of potable water and clean surfaces. Research suggests that that placing a copper alloy surface on six common, frequently touched objects in ICU rooms reduced the risk of HAI (hospital acquired infections) by more than half at all study sites’.136

100

TREATMENT AREAS

Glasgow Royal Infirmary, Glasgow, 2011. Reiach and Hall architects, intensive care unit.

Four zones can be distinguished in the ICU: the patient care zone, the clinical support zone, the unit support zone and the family support zone. ‘Glass partition walls to facilitate surveillance and certain medical equipment have to be installed in an intensive care unit, but designers should try to make them as homely as they can, using natural materials and colors to soften the harshness of the environment they normally provide.’137 Perspective of the Patient Patients in ICUs are closely monitored at all times, drugs are administered if needed, and personnel — medical specialists and a specialized, dedicated nursing staff — are at hand to come to the rescue in case of calamities. ‘The ICU is the stage for many of life’s most extraordinary dramas’, to quote Kirk Hamilton who has researched the design of intensive care units.138 It is, however, a misconception to think that patients do not experience their time in the ICU intensely. Swedish studies have shown that ICU patient spend on average around 60 % of their time (during daytime) in a conscious state. Design efforts in intensive care must therefore pay careful attention to the patient’s needs. There is a point to that, however, because the design and function of ICUs cause a lot of unintended and unnecessary harm to patients who stay in them for durations longer than 14 days. Studies indicate that around 30 % of long-term ICU patients develop posttraumatic stress disorder (PTSD), which diminishes the patients’ ability to return to a balanced life and/or the ability to work again.139 Conditions with a negative impact on patient health are: •C ontinuous disorientation •C ontinuous illumination •E xposure to extreme noise (frequently higher than 60 dB on average)140 •S leep deprivation • Loss of control combined with abundant alarm functions (the latter give the patient the continuous impression of being in a life-threatening situation). Considering the goal of intensive care, namely to keep the patient alive, the design of such facilities must be significantly improved in order to prevent further collateral damage to patients. Early mobilization and reactivation while the patient is still in the ICU has been shown to have a positive effect on his or her health. Studies show that mobilization, including moving the still-ventilated patient, and even mobilizing the unconscious patient, may lead to an average reduction in the length of stay for long-term patients of 1.0 days in the ICU and 1.5 days in general inpatient care. This is not only a significant cost factor but 101

also considerably improves the patient’s quality of life by reducing the risk of loss of muscular tissue.141 ICU design must therefore provide sufficient space and equipment to enable the early mobilization of patients. Functional Perspective ICU care is usually differentiated into three levels: Level I — Intensive care surveillance (IMCU) Patients showing signs of dysfunction in one organ system who require continuous surveillance (monitoring) and minor pharmacological or technical support. These patients are at risk of developing one organ failure, or have recovered from an organ failure and require an elevated level of attention or care. Level II — Intensive therapy (ICU) Patients requiring intensive surveillance and/or a low level of therapy for potential failure of one organ system with life-threatening conditions, organ replacement, machine-assisted ventilation, or continuous kidney replacement therapy. Level III — Intensive therapy (ICU) Patients requiring intensive surveillance and/or a high level of therapy for two existing or potential organ system failures with immediate life-threatening conditions, organ replacement, support systems to maintain blood circulation machine-assisted ventilation, or continuous kidney replacement therapy.142 Considering the condition of patients in ICUs, noise reduction, light management and control of alarm functions must be key parameters for ICU design. Large open-space solutions accommodating several patients in one large room represent hygienic hazards and should not be adopted. Position Relative to Other Departments The intensive care unit is usually adjacent to the medium care unit, offering the possibility of using the latter to scale up when the number of patients in need of intensive care exceeds the number of beds available in the ICU. It goes without saying that ICUs are best located near those departments that accommodate most patients (at risk of) needing close observation and life support after treatment. The operating block is one of these (in the case of complex surgical interventions), the emergency department another. The position next to the operating block ensures a fast transfer to an operating room in case of life-threatening complications needing surgical intervention. In some cases, the patient can be brought into the post-anesthesia care unit (PACU) after the operation (instead of being transferred to an ICU), where he or she can be stabilized by specialized medical staff. This allows for around-the-clock supervision from multiple medical specialists, as the PACU is one of the areas nearest to the operating block. At the same time, it requires the presence of monitoring staff, ensuring that any change in the state of the patient is observed and, if necessary, acted upon. The optimal location of the PACU is debatable, with arguments favoring proximity/integration both to the operating block and to the ICU. Challenges for Future Design Due to efforts to reduce the length of stay in hospitals, the pressure to scale up the intensive care facilities will increase. Integration of continuous monitoring into general inpatient care is therefore probably unavoidable in order to reduce the burden on the limited, and expensive ICU facilities. Future design could include the provision of a post-anesthesia care unit in addition to the ICU; it could serve as a pivot between the OR, OR recovery, emergency and the ICU. This will allow the ICU to focus better on its core activities.

102

TREATMENT AREAS

The following criteria will be important in future ICU design: • Patients’ quality of life • Early mobilization facilities • Reducing the chances of post-ICU traumatic stress disorder • Moving from horizontal design to vertical design, with e.g. the design of ceilings above patients’ beds as an element of healing design •P ACU as the pivot to reorganize ICU care •M anagement of patient fear and anxiety • Balancing health and comfort — allowing optimal supervision and monitoring with maximum comfort for the patient •S timulating and motivating the patient to actively participate in the healing process The Patient Bed The ICU bed allows for extensive customization of the position of the patient, and it is equipped with artificial ventilation, equipment necessary for life support and feeding, and for monitoring of vital functions. The medical staff should be able to move freely around the patient, with rules prescribing a minimum clear area around the patient bed. This is usually 1.8 m, measured from the side of the patient bed, and 1.2 m measured from the foot of the bed. This area should be free of furniture, equipment and any other obstacles, with the exception of life-support equipment. The patient should have easy access from the bed to means of communication with the medical staff. The Patient Room The patient room is the smallest module in an ICU unit. It is recommended that patients have individual rooms and visual access to direct daylight and to an exterior view, so as to minimize the incidence and effects of disorientation. In order to support patient orientation, it is necessary to include a clock and a calendar, set to show the correct time and date, in the room. The calendar, or a whiteboard, can be used to show the timetable and names of the nurses on duty. The patient room should allow for constant supervision. The nurse or the medical supervisor needs a workstation equipped with a computer allowing for monitoring vital signs and handling data input related to the patient’s condition. A washbasin and/or a sanitizing alcohol dispenser allows for easy hand-cleaning before and after consultation or intervention. A locker for the nurses should allow for localized storage of medical equipment, medicine, folders, etc. The patient’s belongings could be stored in a locker outside the unit. The ICU patient usually is in such critical condition that movement outside the bed area is

Bradford Royal Infirmary, Bradford, UK, Bridger Carr Architects, ICU, 2016. The intensive care unit has 16 single rooms grouped in clusters of four, with glass partitioning walls that can be either frosty or transparent; it is endowed with a lighting system that emulates daylight and the rhythm of day and night. INTENSIVE CARE UNIT

103

rarely possible. En-suite toilets or bathrooms are therefore not necessary. However, for situations where the patient is capable of walking (or being transported) to the bathroom, or when the ICU works as a stepped-care unit, a few patient bathrooms at the cluster or unit level are advisable. The Unit The ICU is usually organized in clusters of six to eight patients. This facilitates short travel distance, fast access for the medical staff, close supervision and sufficient nursing backup during emergencies. The staffing levels (e.g. nurses per bed) and levels of expertise required depend on the number of patients and the level of the ICU. Limiting the number of patients per cluster, and placing it under the supervision of one team, also helps to reduce the risk of contamination. Each cluster usually has a supervising nurse and an intensive care specialist. Usually one or two rooms per unit are equipped with a quarantine room with a sluice for highly infectious or very frail patients. Their position should be nearest to the elevators and transport route, in order to minimize contamination risks. The sluice is meant primarily for use by medical staff members as they go in and out of the patient room; where it is also intended for use by patients, it must be wide enough to allow for the passage of the patient’s bed. The Department The ICU has a reception area for visitors, who are usually allowed to visit the patient in small numbers without rooming-in. In some cases, the ICU can accommodate family members wishing to spend the night in a designated area, usually immediately outside the unit. These spaces mostly have a homely, living-room atmosphere. The medical staff discusses the condition of (and treatment plan for) the patient with family and provides psychological support either in these spaces, when necessary or, when possible, in the patient’s room. Some diagnostic imaging can be done in the patient’s room using mobile imaging equipment, but examinations requiring MRI or CT scans will have to be performed in the diagnostic imaging department. Other examinations and interventions such as endoscopy, psychiatric evaluation, physiotherapy and dialysis can be performed in the patient’s room. Each unit must be equipped with a centralized washing area (next to the reception area) for medical staff and visitors. Patients are supervised by teams of nurses, who follow strict hygiene procedures when entering the ICU and who remain in the ICU during the entire shift. Therefore, staff toilets and facilities for relaxation and for deskbound work, as well as a kitchenette with a dining space, need to be part of the ICU. Other back-office facilities required in the ICU include a sterile and non-sterile storage area, a waste storage and disposal area, a satellite pharmacy and meeting rooms. Most of the necessary instruments, medical equipment, supplies and medication are either stored at a central location in the ICU or, in case of a large ICU, at decentralized locations servicing one or more clusters. Clean bed storage is organized at the departmental level, to ensure clean patient transport to, for instance, the operating block or the diagnostic imaging department. The ICU can be configured in various ways of which five typical solutions are presented here: The first model allows the main traffic route to go through the ICU clusters. Although it provides optimal access to direct daylight, it does create a challenge for the hygiene requirements of the ICU clusters. The ICU washing area can no longer function as a filter for patient room access, and, therefore, contamination risk increases due to staff moving between the ICU clusters. Hygiene protocols have to be very scrupulously followed in order to ensure patient safety. The second model distributes the IC rooms parallel to the main traffic corridor, decreasing walking distances and turnover time. In this model, however, direct daylight is 104

TREATMENT AREAS

Office and staff facilities

Reception desk

D B

Office and staff D facilities

Reception desk

Storage and logistics, medication room

Office and staff facilities

Storage and logistics, medication room

Reception desk

medication room

Reception desk

Centralized and decentralized models for supervision inside the ICU A Centralized monitoring station B Decentralized monitoring stations shared by two patient rooms C Individual monitoring stations D Mixed monitoring

Reception desk

unavailable for some patient rooms, although indirect daylight could be provided via the corridor (in case of glazing between patient room and corridor). However, moving shadows due to staff and visitor movements can be a source of confusion and distress for the patient. In the mirrored version of the model, access to daylight is restricted to the outward-facing rooms. Increasing the distance between the units and inserting a patio between them could allow some direct daylight into some patient rooms at the cost of longer walking distances. No matter what the solution, in this model some spaces in the ICU will be deprived of (direct) daylight. The third model, in essence a variant on the second, is reminiscent of earlier hospital plans inasmuch as it allows access to natural light by dividing the ICU into separate wings with wide patios between them. A simple version of this model distributes the ICU units along a main traffic corridor, A allowing support facilities to be located on the other side of Officenumber and the corridor. If the department requires a large of patient beds, the ICU units can staff be mirrored along the main traffic axis. In thisfacilities case, support facilities need to be placed on either side of the ICU units, increasing walking distances. Another disadvantage is that the wings are short, which reduces future flexibility in case there is ever a need to convert these spaces to other uses. The fourth model distributes the ICU around a central patio. Patient rooms have access Storage and to direct daylight, as well as to supportlogistics, facilities. In the case of larger departments, the medication room model can be mirrored along the main traffic route. However, this complex arrangement requires a judicious distribution of vertical connections to allow for fast transportation of patients. The objective should be to ensure that connections to other departments are B roughly equally distant for all ICU patients. Office and staff In the fifth model, all the patient rooms facilities are arranged around a large, central control room giving all of them access to daylight. The monitoring, supervision and working areas of the medical staff and other back-office functions can be organized quite efficiently, but have limited, and indirect, daylight. Using semi-transparent walls in patient rooms increases Storage and the amount of indirect natural light, but logistics, has the disadvantage of creating moving shadows.

Office and staff facilities

Storage and logistics, medication room

Office and staff facilities

INTENSIVE CARE UNIT Storage and logistics, medication room

105

Daylight

egend

Reception/ Office and staff facilities Storage and logistics, medication room

Legend

1. Reception/ Office and staff facilities 2. Storage and logistics, medication room

Main traffic route 2

Daylight

Main traffic route

Daylight

1 2

Main traffic route

Daylight

Main traffic route

106

TREATMENT AREAS

Typical layouts of the ICU Department E A Main traffic route through the ICU ward B Main traffic route parallel to (but outside) the ICU ward C ICUs form separate pavilions connected to the main traffic route D ICUs border a central patio, with the main traffic route on one of its sides E ICUs organized around a centralized control room

Main traffic route

Daylight

1,8 m

Legend Legend Area for medical Area for medical 1 Monitoring pendant 1 Monitoring pendant equipment equipment Adjustable examination examination lamps 2 2 Adjustable lamps pendant ventilator pendant 3 Artificial ventilator 3 Artificial (optional) disinfector (optional) 4 Bedpan disinfector 4 Bedpan 1 1 5 Monitoring station 5 Monitoring station

1,2 m

Legend 1 Monitoring pendant Intensive care room with typical components: examination lamps 2 Adjustable 3 Artificial ventilator pendant specialized patient area (brown) with room 4 Bedpan disinfector (optional) station 5 Monitoring for additional medical equipment (pink),

Area for medical equipment 1,8 m

1,2 m

Legend 1 Monitoring pendant 2 Adjustable examination lamps 3 Artificial ventilator pendant 4 Bedpan disinfector (optional) 5 Monitoring station 5

1,2 m

1,8 m

optional sluice (blue), optional family area (green), (possibly individual) monitoring station (purple)

1,8 m

Area for medical equipment

5 3

1,8 m

4 Legend 1 Monitoring pendant 2 Adjustable examination lamps 3 Artificial ventilator pendant 4 Bedpan disinfector (optional) 5 Monitoring station

1,8 m

Area for medical equipment 1

1,2 m

2 Legend

Area for medical Area for medical equipment

Area for medical Area for medical equipment equipment

equipment

2 Adjustable examination lamps 3 Artificial ventilator pendant 4 Bedpan disinfector (optional) 5 Monitoring station

3 1

1,8 m

Legend

1 Monitoring pendant 1 Monitoring pendant Inpatient room layout equipment examination lamps 2 Adjustable examination 2 Adjustable lamps The room is permanently equipped with pendant pendant ventilator 3 Artificial ventilator 3 Artificial (optional) disinfector (optional) 4 Bedpan disinfector 4 Bedpan 1 1 standard equipment, with the monitoring station station and 5 Monitoring 5 Monitoring ventilation equipment often suspended from the ceiling to preserve as much empty Legend Area for medical floor space as possible pendant 1 Monitoring

Legend Area for medical 1 Monitoring pendant examination2lamps 2 Adjustable equipment 3 Artificial ventilator pendant 4 Bedpan disinfector (optional) 1 station 5 Monitoring

Area for medical equipment

4 3

3 5

3 4

3 5

Legend 1 Monitoring pendant 2 Adjustable examination lamps 3 Artificial ventilator pendant 4 Bedpan disinfector (optional) 5 Monitoring station

5 2

Area for medical equipment

Area for medic equipment

3 INTENSIVE CARE UNIT

107

Fourth floor plan

Third floor plan

Exterior view | Entrance | Oval volume with the patient wards | Access to emergency department

Rey Juan Carlos Hospital

Architect

Rafael de La-Hoz

Client City of Madrid, Public Health Service

Madrid, Spain Completion 2012

148

GENERAL HOSPITALS

Floor area

94,705 m²

Capacity

160 beds

The Rey Juan Carlos Hospital adds a striking note to the Madrid suburb of Móstoles: if it is doesn’t look like a healthcare facility, this may be because, to some, it doesn’t look like a building at all – not in the traditional way at least. Rectangular openings for doors and windows, for instance, a common aspect of almost all buildings, have been banned. Instead, Rafael de La-Hoz Architects designed an abstract composition of a rectangular box that is covered by a screen of narrow horizontal bands in a dark color, which protects the interior against inclement sunlight. This structure is topped by two oval towers clad in bright, shining material that forms

Longitudinal section

diamond-shaped panels, producing a conspicuous contrast with the horizontality of the box below. This sculptural icon does not correspond with its surroundings in any way, neither in its scale nor in its visual characteristics nor in the materials that were chosen. It is a completely introverted complex, a world in itself – and that is precisely what the designers had in mind. Remarkable though this building may be, it is not without precedent. It is a radical reinterpretation of the very well-known hospital type that is often referred to as a ‘matchbox on a muffin’, better known under its German name ‘Breitfuss’, namely a box at the bottom housing the treat-

ment areas, the outpatient area and the emergency department, and separate volumes on top of it accommodating the inpatients. The threestoried box of the Rey Juan Carlos Hospital is made up by three parallel zones divided by two spacious patios: the inpatient wing faces the street and is connected with the main entrance, the central zone is reserved for the treatment areas, while the third zone, separated from the hot floor in the central zone by a calm and serene patio, accommodates the emergency department. The patios are lit by circular skylights, the consultancy rooms of the outpatient department face the street, shielded against direct sunlight

by the impressive screen that envelops the entire low-rise box. The two inpatient wards on top of it are organized around large open patios with gardens. Each tower has five floors of patient rooms, which can be reached via galleries that allow a view of the garden. The rooms face outside; each of the shining panels that clad the walls is pierced by a circular window that provides vistas of the surrounding suburban settlement while special care has been taken to protect the rooms against direct sunlight.

REY JUAN CARLOS HOSPITAL

149

Patient room | Patient bathroom | Main hall | Patio with tilted roof | Entrance

150

GENERAL HOSPITALS

Ground floor plan

First floor plan

WARDS

ICU DIAGNOSIS RADIOLOGY

SURGERY EMERGENCY LOGISTICS

OUTPATIENT ADMINISTRATION REHAB

APARCAMIENTO -2

Diagram showing functions

REY JUAN CARLOS HOSPITAL

151

Elevation

The elegantly curved, wooden façade with the main entrance | View from the parking lot to the main façade | Views of hall at the center of the building | Social area in the lobby

Ruukki Health Clinic

Architect

Alt Architects; Martti Karsikas

Ruukki, Finland Client

Municipality of Siikajoki

Completion

2014

Floor area

910 m²

Located next to a senior citizen’s assisted living and care center, the Ruukki Health Clinic reaches out to the local community, adding a dental clinic and simple healthcare services, among them facilities for childcare. Ruuki is a small community of some 4,500 inhabitants in the province of Oulu, located in the Northern Ostrobothnia region of Finland and the health clinic site is surrounded by pine forests. The building has two linear and one concave façade, resulting in a curved L-shaped plan. Most treatment areas and consulting rooms are located along the perimeter of the outer façade of this

232

OUTPATIENT CLINICS AND HEALTH CENTERS

ET 1

LIIKEKESKUSALUE

314 AP II

35 Y-1 KLT 1 II e=0.30

e=0.20

II e=0.25 LT

Masto h=100 m

VP IE PÄÄT

ET-1 II

Sp 30 m Sp 35 m ET

e=0.20

2 AO I

TIE AN

LR 3

LYS

HÄ

RÖ

4 5

1/2 I 1/2 e=0.25

AP I e=0.20

6 Z

VP MÄKELÄNKANGAS YO III

AP 1 1/2

e=0.25

HÄ

RÖ

0.30

NT IE

KLT-1 II e=0.30

e=0.20as

PA TO T

NS A

34 2

YK I

e=0.25

e=0.20

INK UJ A

e=0.25

HE IK

YS I 3/4

AO I 3/4

LYT 1

AO I 3/4

e=0.20

5 3

AL II e=0.30

e=0.25

IRVANT

UJ KIK MÄ

YS II

T e=0.40

AO I

9 12

e=0.20

TIE

AN IRV

54 13

YV I 3/4 LYT LYT

10m

NU 1

IJA

1 55

AO-1 I e=0.20

T e=0.40

e=0.40

Site plan

L-shaped building; wide ribbon windows offer views of the adjacent pine woods. The inner side of the building is marked by a curved wall that is interspersed with windows in a seemingly random order lending the building’s entrance a humane and playful character. Wooden frames protrude outwards to the square in front, marking the entrances. The façades are clad in larch wood that will gray over time and anodized aluminum. Jutting forward, the wooden roof protects the glazed parts underneath from the impact of inclement weather conditions. Architect Alt Arkkitehdit explains that ‘ample eaves protect the cladding from weather and connect the

Ground floor plan

embracing, free-form wall to the older buildings with its stern but polite profile’. The main entrance in the middle opens to a spacious lobby that gives access to the two corridors that lead to the spaces for consultancy and treatment. The dental care, health care, and child healthcare facilities are distinct units grouped around the central lobby at the core of the building. The end of the corridors are left open, preventing the impression of dead-end streets. Finish birch veneer and white façades give the interior a friendly, almost homely character. Though relatively small, the clinic has

a strong presence, its contemporary architectural language contrasting with the adjacent buildings. The project was a collaboration with Martti Karsikas and was exhibited in the Nordic pavilion at the Venice Biennale 2016.

RUUKKI HEALTH CLINIC

233

www.birkhauser.com

Hospitals as a building type have undergone a substantial evolution in the past few years: Changes in healthcare, the impact of evidence-based medicine and aspects of healthcare economics (such as the clustering of diagnostic procedures in specialized clinics) pose new and different challenges for the designer. Private healthcare facilities herald the paradigm change from the large functional building complex to a design-conscious health institution, sometimes with luxury hotel features. Health centers more devoted to prevention rather than cure have been another important trend. A range of renowned authors from building practice, architectural typology and the healthcare sector explain the principles and requirements for the planning of hospitals and other health buildings. An international case study section documents 40 best-practice projects in six categories: general hospitals, childrenâ&#x20AC;&#x2122;s hospitals, university hospitals, specialized hospitals, outpatient clinics and health centers as well as rehabilitation clinics.