Healing architecture

University of the Holy Spirit of Kaslik Faculty of Fine Arts Department: Architecture

HEALING ARCHITECTURE

Dr. HANY KAHWAJI JANHO.

Joey Harb 201101984

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1. Chapter one: Introduction 1.1. Statement of the problem 1.2. Research question 1.3. Aim and objective 1.4. Research methodology 1.5. Organization of the study 2. Chapter two: Cancer 2.1. Introduction 2.2. Facts about cancer 2.3. Cancer patients 2.4. Treatment 2.4.1. Typical treatment cycles 2.4.2. Sample timelines 2.4.3. Focus patient undergoing chemotherapy 2.5. Cancer and stress 2.6. Cancer in Lebanon 2.6.1. Cancer studies in Lebanon 2.6.2. Cancer projections till 2020 2.6.3. Cancer centers in Lebanon 2.7. Cancer and the concept of healing architecture 3. Chapter three: Healing architecture 3.1. Introduction 3.2. The process and involvement of healing 3.2.1. The healing process through medical hospital 3.2.2. The healing process through natural environment 3.3. Evidence based design 3.3.1. Definition 3.3.2. Evidence based design factors 3.3.2.1.

Light 3.3.2.1.1.

Light quality 3.3.2.1.2.

The healing powers of light 3.3.2.2.

Acoustics 3.3.2.2.1.

Noise and stress 3.3.2.2.2.

Music therapy 3.3.2.3.

Relation to outdoor areas 3.3.2.4.

Personal and social space 3.3.2.5.

Indoor climate 3.3.3. Evidence based design factors in the cancer center 4. Chapter four: case studies 4.1. Cancer center welfare home and research institute, Kolkata 4.2. Tata medical center , kolkata P a g e 2 | 62

4.3. Shirdi sai baba cancer hospital, manipal 4.4. The Cleveland Clinic Abu Dhabi Hospital 4.5. Rush University Medical Center 4.6. Spaulding Hospital 5. Chapter five: design strategy 5.1. Program 5.2. Site criteria 5.3. Site proposition 6. Bibliography

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1. Chapter one: Introduction 1.1.Statement of the problem According to the National Cancer Registry activity in Lebanon, about 8868 cancer cases were diagnosed in Lebanon in 2007.

Which is increasing in its incidence yearly providing high rates of cancer cases year by year.

Cancer is a disease that poses enormous challenges to research, because every cancer is different and its course can vary immensely even from one patient to the other, so the goal in the trials of cancer treatment is to provide multiple plans with highly effective programs became more difficult.

One of the main problems that have been faced the last several years by the patients during their course of treatment is the psychological side and how it affected them and so their treatment plan and this was clearly reflected on the outcome of treatment and their health, and so then many researches proved that the psychological insult have an important role during treatment providing new protocols of therapy.

The presence of multiple kinds and activities in the hospital is a new concept of therapy is now used and have proven its efficacy, it would help patients in performing their daily activities and reducing their negative energy and depression episodes during the course of treatment especially post-chemotherapy or surgeries.

In the world today, cancer is second on the list of leading causes of death right behind cardiovascular diseases. In Lebanon there are 28 facilities (clinics and hospitals) which provide treatment for all people suffering from cancer, but there is only one center in Lebanon that dedicated to fighting cancer and it is for children, it is called Children Cancer Center-Saint Jude, and it is located in Hamra in Beirut in the American University Hospital.

1.2.Research question Healing in psychology, medicine and even in the spiritual sense involves a process where the patient or the recipient receives a physically external antidote in order to help them heal. It is then up to the patient to take the inward step of acceptance and retrospection in order to progress the healing. However, if we ignore the qualities of physical context it could involuntarily slow the healing process.

How then, can the architecture have an active role in the healing process of cancer patients?

1.3.Aim and objective People tend to ignore the sensitivity of cancer patients and the importance of increasing the quality of life.

The center attempts to provide some insight into how a patient direly needs palliative care, while the architecture should acts as a spiritual and meditative place for relaxation and care. Through P a g e 4 | 62

the human senses (sight, sound, smell), where the hospice environment has been created which provides a sense of strength and acceptance for cancer patients.

The project takes its point of departure in the theme of “healing architecture”, which declares that architecture can have a positive effect on the healing and health care outcomes of its users, and in order to determine and understand which architectural factors specifically have a healing effect on cancer patients.

Different research revolving this has resulted in evidence, which prove that the architectural design can support the healing of a patient, psychologically as well as physiologically, through the integration of the architectural means of qualitative light, acoustics and atmosphere as well as through planning in the sense of creating a possibility for privacy, connection to outdoor spaces and spaces for social interaction with friends, family or other patients.

Cancer patients suffer from side effects from their cancer disease and the treatment. The conditions are psychological as well as physical comprising stress, fatigue, depression, pain and anxiety, that’s why evidence from different research within healing architecture proves certain architectural elements’ effect on health care outcomes.

The factors of light, acoustics, flow, relations to nature as well as personal and social space are important to consider in relation to the cancer center, as they have proven to relieve and decrease conditions like those experienced by cancer patients.

Healing architecture implies an evidence based design process, where the evidence based architectural factors are important parameters throughout the design process.

Finally the main goal of this project is to enhance capacity-building in our region to improve cancer care. We would like to enlist also the assistance in training health care professionals in the region through various training mechanisms, including workshops and researches. Also the center should contribute to keeping and improving the quality of life of the cancer patients and their families with physical, psychological and social elements. It is the desire that the building will stand out through its architectural expression and create motivation and invite to social interaction, physical motion and personal transformation.

1.4.Research methodology The project revolves around the creation of a cancer center through the concept of healing architecture. Healing architecture is founded on evidence based design, which will be analyzed in regards of concretizing the factors relevant in this project. Other literature will be integrated to supplement the evidence basis and case studies will be carried out to gain knowledge and inspiration about the cancer centers.

The evidence based design factors studied through healing architecture will form the base of the study of the cases, and be supplemented by the experiences gained there in regards of the architectural effects, the atmosphere and other important parameters. Together this theoretically as well as practically gained knowledge will be the foundation for the design process.

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The project will primarily evolve around the technical theme of light, as it is an important factor within healing architecture and when dealing with cancer patients. The indoor climate in terms of thermal conditions as well as the air quality will play an important role, and the acoustical will also be taken into consideration.

1.5.Organization of the study

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2. Chapter two: Cancer 2.1.Introduction The World Health Organization (WHO) defines health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.

Cancer is the Latin word for crab. The ancients used the word to mean a malignancy, doubtless because of the crab-like tenacity a malignant tumor sometimes seems to show in grasping the tissues it invades. Cancer may also be called malignancy, a malignant tumor, or a neoplasm (literally, a new growth).

Oxford University press (British and world English dictionary) defined cancer as a disease caused by an uncontrolled division of abnormal cells on a part of the body, a malignant growth or tumor resulting from an uncontrolled division of cells. Most skin cancers are curable.

According to medical dictionary, cancer is not just one disease, but a large group of almost 100 diseases. Its two main characteristics are uncontrolled growth of the cells in the human body and ability of these cells to migrate from one original set and spread to distant sites. If the spread is not controlled, cancer can result to death.

More than 12 million people are affected by cancer worldwide. Following stroke and heart disease, cancer is the second leading cause of death with 13% of worldwide mortalities.

Cancer can attack anyone since the occurrence of cancer increases as individual’s age; most of the cases are seen in adults, middle- age or older. Sixty percent of all cancers are diagnosed in people who are older than 65years of age.

Cancer by definition is a disease of the genes. A gene is a small part of DNA, which is the molecule of the cell. Genes make ‘protein’ which are the ultimate work horses of the cells.

Cancer is an abnormal growth of cells which tend to proliferate in an uncontrolled way and, in some cases, to metastasize (spread). Cancer is not one disease. It is a group of more than 100 different and distinctive diseases. Cancer can involve any tissue of the body and have many different forms in each body area. Most cancers are named for the type of cell or organ in which they start. If a cancer spreads (metastasizes), the new tumor bears the same name as the original (primary) tumor.

Major risk factors for cancer are: Radiation, tobacco, alcohol, diet, sexual and reproductive behavior, infections agents, family history, occupation, environment and pollution.

Cancer has become a major source of morbidity and mortality globally.

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2.2.Facts about Cancer Over 20,000 people die of Cancer every day, it causes more deaths than AIDS, tuberculosis, and malaria combined, and there are more than 100 types of cancers; any part of the body can be affected.

Over 30% of cancer could be prevented by avoiding tobacco and alcohol, having a healthy diet and physical activity, but exercise, like walking, can reduce breast cancer risk by 25%, also a Marijuana-derived compound forces cancer cells to freeze and prevents them from spreading.

Multivitamins increase the risk of cancer and heart disease, according to recent studies and there are more skin cancer cases due to indoor tanning than lung cancer cases due to smoking.

There are four primary cancer therapies which are surgery, chemotherapy, radiation and biologic therapy.

There are 28 million cancer survivors worldwide.

Researchers believe that more than half of all cancers and cancer deaths are potentially preventable.

2.3.Cancer patients Cancer is a widespread and often feared disease because it can affect all people, old as young, healthy as unhealthy and because of the often harsh treatment course and the sometimes deadly outcome. Consequently, being diagnosed and living with cancer bring many unpleasant psychological emotions and reactions alongside physical side effects from the treatment and illness.

Physical side effects from the cancer decease and the treatments affects people individually, but common physical reactions are: loss of hair, pain, fatigue, breathing problems, nausea, loss of appetite and weight.

However the psychological reactions to the illness and the treatment course can be just as severe as the physical reactions in such.

Previously, cancer has been seen as something “impure�, why some cancer diagnosed people experience dissociation or stigmatization from the near surroundings making them feel unclean and tabooed.

Furthermore, the uncertainty surrounding the disease and the treatments often bring other psychological reactions such as anxiety and worry which can be expressed through grief, anger, fear and despair. These emotions may also bring physical reactions such as increased heartbeat, difficulties to breathe, dizziness and tensions in the body.

The reactions usually continue to affect the patient in a greater or less extent many years after the cancer treatment due to the uncertainty related to the risk of a renewed outbreak of the cancer.

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An investigation from the Danish Cancer Society presented in 2005 shows that people diagnosed with cancer are at great risk of becoming severely depressed up to ten years after their treatment.

This also indicates that many cancer patients in general are more despondent and suffer more from mild depressions than the rest of the population.

The physical and psychological reactions to cancer and cancer treatments moreover commonly result in an increased level of stress hormones which may be affecting many cancer patients.

2.4.Treatment One of the deadliest diseases of this century is cancer. According to reports by W.H.O. one out of three women and one out of four men are prone to getting cancer in the world. Now with such alarming figures the task of hospitals and doctors has become very challenging. But with the advancement of technology its cure has become possible provided the disease is diagnosed in its early phase. Today the use of modern technology has brought the cure rate of cancer to almost 70-80%.

List of various treatment methods of cancer Chemotherapy: Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen. The most common chemotherapy agents act by killing cells that divide rapidly, one of the main properties of most cancer cells. This means that chemotherapy also harms cells that divide rapidly under normal circumstances.

Surgery: Surgical oncology is the branch of surgery which focuses on the surgical management of cancer.

Using various methods of surgery including minimally invasive surgery techniques seeks to remove cancerous cells.

Radiation Therapy: It is the medical use of ionizing radiation, generally as part of cancer treatment to control or kill malignant cells. Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body.

Other Treatment Hormone manipulation is well established, particularly in the treatment of breast and prostate cancer One possible treatment for cancer involves monoclonal antibodies that bind only to cancer cellspecific antigens and induce an immunological response against the target.

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2.4.1. Typical treatment cycles Cancer treatment plans vary depending on the patient’s specific condition and disease. The following three examples, were taken from an example patient with advanced Inflammatory breast Cancer. A combination of chemotherapy, radiation, and injections are often used in 7 or 14 day cycles that repeat for several months.

7-DAY TREATMENT CYCLE Chemotherapy/Radiation (x12 Repeat)

14-DAY TREATMENT CYCLE Chemotherapy, Neupogen (x8 Repeat)

14-DAY TREATMENT CYCLE Chemotherapy, Neulasta (x8 Repeat)

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2.4.2. Sample timelines Cancer treatments alone often cause a great deal of damage to the body. This creates a lot of stress on top of the stress of dealing with the disease. Those are some sample timelines for a typical day as a cancer patient, an atypical day as a cancer patient (when a blood transfusion is needed due to low, white-blood-cell counts from treatments), and a typical day for a healthy person who is not undergoing cancer treatment.

Stress and anxiety levels tend to be much higher in patients who are frequently at the hospital, and they suffer from uncomfortable symptoms from the medications. This weaker condition makes it harder to cope with this stress.

Comparing Schedules and Anxiety Levels: Chemo Patient vs. Healthy Person

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2.4.3. Focus patient undergoing chemotherapy After diagnosis, patients usually begin treatment immediately, which can last anywhere from two months and beyond depending on the severity of the disease, prognosis, and progress as treatment takes place. The treatment plan can change significantly as time progresses. Unfortunately, many cancer patients recover only to find the cancer has spread. At this time, they typically resume treatment, either similar or different from before. Treatments widely vary by person and by stage.

Typical cycle for patients receiving chemotherapy (typically cancer patients)

Cancer Fatigue is one of the most difficult challenges cancer patients face and is not often treated because it cannot be directly measured, and patients often do not bring it to the attention of their caregivers.2 Among other symptoms such as nausea, dizziness, and hair loss, cancer fatigue, more severe than regular fatigue, tends to get worse with more chemo and radiation treatments How many of these symptoms and deaths could be avoided by minimizing stress from healing spaces?

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Cancer Fatigue

Common Symptoms of Chemotherapy

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2.5.Cancer and stress Stress is provoked both through inner psychological stressors, which can be caused by the cancer patients’ fear concerning future treatments, possible pain, possible complications and external physical stressors caused by sensory perceptions from for instance the new hospital environment in which the patient suddenly finds itself.

Stress can be described as an instinctive survival strategy triggering feelings like anxiety and worry. These can be caused by outer stressors affecting the senses, eyes, ears, skin and nose that are the human version of an alert system. Outer stressors can be unpleasant visual perceptions, galling temperature levels, unfamiliar noise or smells.

Signals perceived by the senses are sent to the brain that decides whether the situation is dangerous or not. If perceived as threatening the response will be an increased level of stress hormones affecting the individual both physically and psychologically.

The external factors have a greater impact on the development of stress, than previously recognized, why the environment surrounding the patient can be an important issue in the health care outcome.

If the factors effecting the stress level are not altered it can result in a chronic condition of stress which is damaging to the body and the immune system, decreasing the ability to lower the stress levels in the body and return to normal life.

It is widely recognized that stress can cause damage to the immune system due to a release of stress hormones adrenalin and noradrenalin in the body that binds to the natural killer cells of the immune system and lowers their activity critically. However opinions are split in the question of stress and the effect it has on the healing process of cancer patients. Some investigations are verifying the hypothesis of stress provoking a return of cancer whilst others are dismissing it.

The question arises because many investigations show that the immune system actually recognizes and tries to defeat cancer cells, however the cancer cells seem to have an ability to turn off the killer cells meaning the natural immune system is not able to defeat cancer.

Despite the fact that surveys prove different results, scientists have through the last century been searching for a link between the immune system and cancer. The natural immune system is most likely unable to defeat cancer, but treatment improving specific parts of the system focusing on defeating cancer have proved successful, and thus it has become part of the treatment course for many cancer diseases.

Some surveys even suggest that the natural immune system plays an important part in the recovery of cancer patients after surgery, as the operation releases many small cancer cells that are not resistant to immune killer cells, why the natural immune system will be able to defeat the remaining cancer, avoiding a renewed outbreak.

After all, stress in general is a severe negative condition and it affects or implies other health care outcomes both directly and adversely such as heart conditions and instability in other major organs. In addition to afflicting patients, stress is furthermore a major burden for the relatives, and likewise it has proven to be a major problem amongst health care environment staff.

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2.6.Cancer in Lebanon 2.6.1. Cancer Studies in Lebanon Lebanese population based cancer registry in 2007 recorded 8868 cases of cancer, with 4,445 (50.1%) in females and 4,401 (49.9%) in males. The age group with the highest percentage of cancer cases was that of 70 years and above (27%) and the least affected was that below the age of 30 (8%). The most common type of cancer was for the malignant tumor of the breast cancer with a rate of 20%, whereas the least frequent one was malignant tumors in the bones and articular cartilages (1%). For women, the highest rate was for breast cancer (39%) and the lowest was that of malignant tumors in bones and articular cartilages (0.9%). For men, the highest rates were for the malignant tumors of the genital organs (19%), malignant tumor of the lip, the buccal cavity and the pharynx (17%), malignant tumors of the respiratory and intra-thoracic organs (17%), and malignant tumors of urinary tracts (16%), whereas the lowest rate was for the malignant tumor of the breast (0.5%).

The first national cancer surveillance study conducted by Abou Daoud in 1966 revealed that male cancer incidence for all sites was 102.8 and 104.1 for females per 100,000 population.

The next study done by Shamseddine, gathering national cancer data showed that the cancer incidence rates by 1998 have increased by a third since Abou Daoud’s study, recording 154.2 and 143.8 for males and females per 100,000 respectively.

National Cancer Registry activity in Lebanon started in 2003 and reported rates of 179.3 and 190.3 for males and females respectively.

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Distribution of patients suffering from cancer in Lebanon (2007) According to the “National health statistics report in Lebanon in 2012�

Source: MOPH, 2007, Cancer Records.

2.6.2. Cancer Projections till 2020 To further investigate cancer incidence trends in Lebanon, Shamseddine used the National cancer Registry data from 2003-2008, used its trend to predict cancer incidence rates for the next decade.

Estimates from this study predict that overall cancer will reach 361 and 312 cancer cases per 100,000 for males and females respectively by 2020.

An increase is expected for both males and females, knowing that by 2025 the elderly population aged over 60 years will constitute around 10% of the total population.

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Cancer incidence projection in males 2020

Cancer incidence projection in females 2020

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2.6.3. Cancer centers in Lebanon There is only one center in Lebanon that dedicated to fighting cancer for children and it is called Children Cancer Center-Saint Jude. It is located in Hamra in Beirut in the American University Hospital.

But there are 28 other facilities (clinics and hospitals) which provide treatment for all people suffering from cancer and they are: Rizk Hospital (Ashrafieh) Sahel General Hospital (Airport Highway) Arz Hospital (Zalka) Rafic Al Hariri University Hospital (Bir Hassan) Al Islami Hospital (Tripoli) Yazegi Laboratory (Ashrafieh) Ain W Zein Hospital (Chouf) United Medical Group (Hamra) Saint Georges Hospital (Ashrafieh) Abou Jawdeh Hospital (Jal Al Dib) Hotel Dieu de France Hospital (Ashrafieh) Hayek Hospital (Horsh Tabet) Sanofi-Aventis Company (Beirut) Sacre Coeur Hospital (Hazmieh) Bahman Hospital (Haret Hraik) Geitawi Hospital (Ashrafieh) Makassed Hospital (Tarik Al Jadideh) Jabal Amel Hospital (Tyr) Labib Medical Hospital (Saida) Talshiha Hospital (Zahle) Trad Hospital (Clemenceau) Saint Therese Hospital (Hadath) Notre Dame de Secours Hospital (Jbeil) Middle East Hospital (Ramlet Al Baida) Al Hayat Hospital (Ain El Remaneh) St. Georges Hospital (Ajaltoun) Dalaa Hospital (Saida) Hammoud Hospital (Saida)

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2.7.The cancer center and the concept of healing architecture.

Cancer patients suffer from psychological and physical conditions, such as stress, depression, fatigue and pain. This worsens their quality of life and has negative impacts on their recovery.

Is seems evident that the patients will benefit from a cancer center as a supplement to the hospital treatment.

Here the environment will relax and stimulate the senses positively, and counselling, therapy, courses, creative and physical activities will be offered focusing on rebalancing the patient and the relatives in order to help them deal with the disease and maintain quality of life. Healing architecture is a relatively new concept and most surveys focus on hospital situations. Yet, they paint a joint picture and imply a way to obtain improved results that are also highly relevant considering the rehabilitation of cancer patients.

Different research form the foundation of evidence Based Design that forms the base of Healing Architecture.

Diagram showing the idea behind the implementation of the healing architecture design concept in the new cancer center.

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3. Chapter three: Healing architecture 3.1. Introduction Healing architecture and the concept of Healing environments have been researched on over the past century with an emphasis at broadening the knowledge that exists on the patient safety and comfort; physician and staff efficiency; and visitor experience.

Spaces are good mediums for affecting emotions. In places where intense emotions run high, materials, sounds, smells, light, and color have an enormous influence on how people perceive themselves and cope with their situations. In hospital healing spaces, the patient’s experience is often undervalued, overlooked by the functions and operations of the medical treatments and busy schedules.

The human body has an incredible ability to “self-heal” when put into positive healing environments. This healing is enabled by the ability of the body to ‘tap into our internal pharmacies’ by responding to the spaces around them. One of the body’s most effective ways of healing is through means of releasing chemicals in the brain such as endorphins (dopamine) which have the ability to reduce pain and swelling, lead to feelings of euphoria, modulate appetite, and enhance the immune response. Certain elements in environments such as color, light, and natural landscapes can contribute to the body’s ability to self-heal.

This can increase one’s chances of healing faster. Many contemporary healing spaces have become so function-oriented that they lack many of these aspects in their design.

3.2.The Process and Involvement of Healing Healing is the process of the restoration of health to an unbalanced, diseased or damaged organism. Healing may be physical or psychological and not without the mutual reception of these two dimensions of human health.

3.2.1. The Healing Process through Medical Hospital The process of healing in a hospital is departmentalized with every department providing care at a higher and supportive role to the previous. These departments are mainly outpatient, diagnostic and treatment, inpatient, administration and service departments. Higher level hospitals have the research and training departments.

The process of healing mainly revolves around the outpatient, diagnostic and treatment and the inpatient departments for the patient, physician, nurses and visitors. These are the environments within which they operate through the process of healing to the patient.

The human body, mind and spirit need certain conducive environments for it to function at optimum capacity and the natural environment can therefore help support the medical process of healing through incorporation of good design of hospital environments by enhancing surrounding s and engaging hospital occupants in safe, relaxed surrounding.

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3.2.2. Healing Process through Natural Environment More than 1,000 research studies suggest healthcare design that incorporates modern medicine with benefits of the natural environment can improve patient care and medical outcomes and can decrease medical errors and waste.

Cynthia McCullough in her book Evidence Based Design for Healthcare Facilities notes that the central focus of natural environmental design today is directed toward patient comfort and subsequently, staff has reaped the benefits of working in these improved surroundings. She further notes that the incorporation of environmental strategies in hospital design towards supporting the medical process of healing (Evidence Based Design) can lead to the creation of healing environments.

3.3. Evidence based design 3.3.1. Definition The concept of healing architecture is founded on the evidence based design method, meaning the design of health care environments is increasingly guided by research linking the physical environment to healthcare outcomes. Thus the term of evidence based design describes a method for qualifying and developing qualitative architecture based on scientifically proved knowledge that has come out of many different investigations, analyses and statistics. Evidence based design does not only comprise a design concept but also includes the measurable effect of the built environment.

The research done within the field of healing architecture is of various qualities, done by different professions and disciplines, and not all can be described as generally credible empirical evidence, as it is not generated through randomized clinical trials or experiments, and will be defined merely as quasi-experimental research, epidemiological investigations or as observational studies. However, the research paints a reliable, joint pattern of certain environmental factors having an influence on the health care outcomes, and it confirms how a range of design characteristics and interventions, meaning evidence based design, can help improve healthcare architecture. The research reliability seems further strengthened, as the results are consistent and agrees with hypotheses based on earlier knowledge. Four general types of outcomes, that categorize the research, can be listed: The patient safety, in relation to infections, medical errors, and falls; The patient’s and relatives’ wellbeing, such as pain, sleep, stress, comfort, depression, navigation, privacy, communication, social support, and satisfaction; Staff outcomes, such as injuries, stress, work effectiveness and satisfaction. In regards of this project the outcomes relating the patient’s and relatives’ wellbeing as well as the staff will be of primary concern.

The evidence from most of the research within the field of healing architecture comes from hospital architecture. Much evidence relates to in-patient situations, and in this matter it can be difficult to transfer the evidence to a situation within a rehabilitation center, as in the cancer center. Furthermore it always needs to be taken into consideration, when dealing with evidence based design that the different research relies much on the specific types of patients, their specific situation and the specific hospital unit, meaning it cannot be transferred directly to other P a g e 21 | 62

cases, as for instance the cancer patients in this project. For this reason it is an important aspect, that the evidence is looked upon with critical eyes and interpreted critically in relation to the specific design task. Evidence based architectural elements in relation to this project will be described further in the following and it will be considered how they relate to this project and what effect they may have.

Architecture is difficult to measure, as it affects the human being on multiple levels, through multiple senses, empirically and phenomenologically. The aspects of aesthetics play a role in the overall experience of a building, whether it is perceived as attractive, comfortable, pleasant, relaxing or the opposite. As a supplement to the evidence based design, it will be necessary to integrate other theories and cases of architecture to obtain the desired atmosphere and ambience in the architecture in relation to creating a cancer center.

3.3.2. Evidence based design factors There is some architectural factors, which can be altered and influenced through the architectural design and which have been proven on various levels to have an effect on the healing process of patients within health care facilities.

From the analysis of the cancer patients different issues are listed, psychological as well as physical side effects and which needs they will imply.

The factors of light, acoustics, flow, personal space, social space and relation to outdoor spaces are found relevant for the project as they all seem to have an influence on the physiological as well as the physical health of cancer patients. They can contribute to creating a calm, secure, comfortable and motivating environment, and help relieve the stress, the anxiety and the depression the cancer patients may feel. These factors will be analyzed and described in the following pages, followed by a summary of the design parameters of this project.

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Factors that may positively meet the needs of the users experiencing stress.

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3.3.2.1. Light Observational and interview based surveys have proven the fact, that daylight, not independent of windows, is of high importance in health care settings. Patients, relatives and staff all appreciate well-lit spaces and daylight plays an important role in their wellbeing and satisfaction and the overall experience of a physical environment.

Much research revolve around how daylight seems to be pain reducing, mood elevating and sleep improving, and in many cases result in lower duration of hospitalization, reduced use of pain medicaments and less experienced stress.

Furthermore, improved daylight qualities in hospitals have proven to have a significant effect on medication errors as well as injuries among patients and staff.

Cancer patients often suffer from increased stress, depression, insomnia or fatigue as well as an impaired immune system. The evidence based design in relation to light quality in the cancer center will mainly concentrate on results in relation to these health conditions, but naturally also the work conditions of the staff.

Light affects the human being through the eye and through the skin. Skin exposure to light is related to the vitamin D production in the body, thereby affecting several mechanisms within the body, such as strengthening the immune system, the memory and the cognitive ability.

Eye exposure to light has an effect on the human being, physiologically as well as psychologically. Light affects the circadian rhythm, meaning the 24 hour cycle of the human body, as the retina’s exposure to light is directly connected to the melatonin suppression in the body. The light exposure can be said to be what synchronizes the body to the day cycle and assures the timings of physiological rhythms. Less light increases the melatonin level, or in other words fails to suppress it, and one feels sleepy, lazy and ineffective. The light exposure during the day has proven to have a major effect on the sleep quality during the night. Also it is becoming more and more evident, that light/dark cycles regulate many human behaviors including seasonal depression, sleep patterns, body temperatures, brain activity and performance.

When it comes to the psychological effect of light, is has not been fully understood how eye exposure to light can improve mood and help work as a treatment against depression. There are assumptions that the circadian rhythm is closely related to the systems in the body that control the levels of serotonin and norepinephrine, which are implicated in depression and often are what antidepressant medicaments need to increase Two aspects occur, when dealing with light: light for vision and light for therapy Investigations show, that where certain levels of illuminance is adequate for vision, it has no therapeutic effect, meaning it is not light enough to suppress the melatonin level and synchronize the day cycle, or improve the mood and decrease depression. The light conditions in the cancer center is to consider work conditions for the staff as well as for visitors, but also to consider the light as a therapeutic factor in the building.

As with other research within the field of healing architecture, the studies made are of various qualities and they should be considered from the fact, that they together show a pattern, that through exposure to intensive, bright light at certain durations a day, the patients sleep rhythm improves as well as mood disorders such as depression progresses positively. It is important to consider the risk for glare and discomfort, in which case it is most likely to lose its effect, as people would squint, hence become tense and feel uncomfortable.

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In regards of cancer patients it should be taken into careful consideration, that some may be sensitive to large amounts of direct light, why it is important to avoid this in the building.

3.3.2.1.1. Light quality Light has been investigated as an evidence based design factor and it has been described how it has a healing effect on fatigue, pain and depression, commonly experienced by cancer patients.

Accordingly, the following section seeks to define qualitative aspects of light in order to obtain a general understanding of qualitative lighting in architecture in relation to atmosphere and expression.

Light is highly influential in our perceptions of space. The exact same light can accentuate very different expressions trough a change of light, openings and position.

There are two sources of light in architecture; natural daylight (including skylight and reflected light) and artificial light. The last is controllable whereas the first is ever changing.

Daylight has an ability to bring life into an environment through a constant change from morning to evening, throughout the year in color as well as in intensity, creating an infinite variety of movements and effects such as color, textures and contrasts. Surveys suggest that people generally prefer rooms with windows indicating that daylight creates a more pleasant and satisfactory interior than electric light.

3.3.2.1.2. The healing powers of light Biological organisms, including the human species, need natural light to grow, reproduce and behave positively. Historically entire civilizations have been centered on the sun.

Today, the positive effects associated with patient exposure to healthy levels of natural light have been documented through evidence based research studies. The benefits include decreased levels of patient depression, agitation, stress and pain, as well as vitamin deficiencies. This evidence is now allowing us to include natural light in our healing environments. This evidence supports the need for designs to maximize the amount of natural light.

The connection between light and health has been made throughout history. Early civilizations had seen the importance of the sun, and had centered entire societies on its existence. The great Egyptian polymath Imhotep had made the historical connection between the sun, architecture and health. Also Roman civilizations in the third century AD created laws on the right to light, and meticulously oriented their villas, public baths and cities around the sun.

Following this, exposing oneself to the sun was considered a form of preventative medicine, and natural forms of therapy such as sunbathing and heliotherapy were introduced into modern societies. Architects therefore incorporated these new discoveries into the building forms of the modern architectural movement.

By minimizing the amount of natural light that patients are exposed to, the body's circadian rhythm becomes compromised. Studies have been published demonstrating that increasing natural and artificial light helps to reduce depression and seasonal affective disorder within patients.

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3.3.2.2.Acoustics Hearing is one of the senses that constitute the human alert system and contrary to the eyesight it cannot be turned off. Accordingly, unpleasant noise has a negative effect on people bringing psychological reactions such as irritation, fatigue, inattention and low pain threshold.

Consequently, it has been found highly relevant to implement sound or the reduction of noise as a design parameter in the process of designing a cancer considering the impact cancer has on the users of the new center concerning both physical and psychological reactions entailing a need for a relaxing and soothing environment that helps reduce stress and anxiety

Diagram showing some of the negative effects noise may have on people.

3.3.2.2.1. Noise and stress Noise affects all people, well as unwell, and it has been proven to negatively affect the immune system. Surveys suggest that noise of more than 50 dB activates the production of stress hormones, thus implicitly affecting the efficiency of the immune system, which especially for cancer patients is assumed to be an important part of the recovery process. Additionally, noise has been proven to provoke the experience of pain through a lowering of the pain threshold.

There are different types of noise prompting different psychological reactions. The body relatively quickly gets accustomed to constant noise, whereas sudden noises such as telephones ringing, load speaking or yelling immediately will cause an activation of stress hormones.

However, the exposition to constant noise still has a negative psychological effect on the body inducing irritation, fatigue and despondency which for staff working at hospitals has been proven to affect the psychosocial working environment and efficiency. The working environment in hospitals is generally more hectic than in the cancer center. Furthermore, the machinery and alarm systems contributing to creating high noise levels will not be present in the center. Yet, noise may just be caused by bad room acoustics creating long reverberation times for speech which often implies louder speech or by the lacking of implemented building acoustics allowing external noise such as traffic to enter the building.

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Noise affects the physical as well as the psychological state complicating the healing process of patients, as it induces stress and affects the psychosocial working environment for the staff. Thus the importance of implementing noise reduction in an early stage of a building design has been found highly relevant in this project of creating a cancer center, that can support the healing process of cancer patients through a soothing and relaxed environment, suppressing anxiety and stress and helping to maintain quality in life despite cancer.

3.3.2.2.2. Music Therapy Sound in hospital environments can also positively impact the healing process. Music therapy has positive impacts on the building occupant. Patient heart rate, anxiety levels, respiratory rates and temperatures were reduced.

Music therapy has been used in many applications including intensive care, coronary care, maternity, oncology and pediatric care, patients in the ambulatory setting, and more specifically the day surgery setting, indicated that music therapy reduced their anxiety levels during recovery.

According to the American Music Therapy Association, there is a considerable body of knowledge to support the benefits and effectiveness of music therapy. They have found that music is generally used in hospitals to alleviate pain in conjunction with anesthesia or pain medication. Other benefits of music therapy include elevating patients’ mood and counteracting depression; promoting movement for physical rehabilitation; calming or sedating, often to induce sleep; counteracting apprehension or fear; and lessening muscle tension for the purpose of relaxation, including the autonomic nervous system.

Music therapy is a versatile therapy that can be delivered in either a group or individual setting, music therapy can take on many different forms. At its most basic, it involves simply playing music for patients to listen to. More elaborate forms can become songwriting for patients, or musical performance involving patients. Music therapy may be offered to patients while they sit in a chemotherapy chair and receive an infusion, or it can occur in a dedicated or common central space within a facility.

This treatment has been demonstrated to improve quality of life, help patients to vocalize and express their experience and emotions, reduce stress levels, and ease physical pain or discomfort from treatment or from the cancer itself.

3.3.2.3.Relation to outdoor areas The possibility to see or to stay in a green environment has been proven to affect the psychological and physical wellbeing of humans positively in relation to several factors, why it has great relevance to this project theme of designing a new cancer center.

Reducing stress Several studies of people in non-health care situations indicate that real or simulated views of nature produce substantial restoration from stress. This hypothesis has been verified through P a g e 27 | 62

psychological surveys concluding positive emotional, psychological, and physiological changes and a reduction of negative emotions such as anxiety, worry and anger.

Furthermore, the theory has been documented through physiological investigations proving among others a reduced nervous system activity, an increase of alpha rhythms in the brain, longer time interval between heart beats, and a lowering of the pulse and blood pressure. The positive physiological effects are present within three minutes or as fast as within few seconds in certain systems, indicating the relevance of implementing this parameter in the design of the new center where the amount of time used in the center is individual. A study of female cancer patients furthermore show a reduction of anxiety and symptomatic distress by providing them with a virtual nature walk, while in bed or in a hospital room.

The resistance towards stress and the ability to overcome stress have been proven to be increased for people watching pictures or videos of nature compared to people watching videos of urban environments.

Other surveys suggest a beneficial restorative effect of providing access to gardens for stressed patients, their relatives and staff working at hospitals.

Well-designed gardens implying peace, the possibility to be private, and areas encouraging to social interaction not only provides restorative views of nature but also induce other mechanisms, such as fostering access to social support, restorative escape, and control with respect to the often stressful clinical environments at hospitals. Furthermore surveys suggest that the implementation of water, green foliage, and grassy spaces with trees together with practical things such as chairs, tables and canopies increases the use and the pleasure of using them.

Reducing pain Studies additionally indicate that viewing nature may reduce patient’s pain through increasing the production of positive emotions, reducing stress and distracting patients from focusing on their pain. The theory of distraction indicate that the experience of pain requires extensive conscious attention thus if patients are diverted by a pleasant distraction such as nature views, their attention will not be solely focused on their pain, why the experienced feeling of pain is reduced. The more engaging the environmental distraction the greater the pain reduction.

Several surveys both psychological as well as physical are emphasizing the theory of nature views lowering pain indicated through less use of pain medication and higher pain thresholds in patients.

Conclusion The view of nature has a positive effect both psychologically and physically on all people in relation to stress and pain reduction why the implementation of view and access to nature is highly relevant in this project. Especially considering the course of creating a soothing and relaxing environment for both users, relatives and staff reducing the stressful emotions often following in the wake of the diagnosis. Many cancer patients suffer from physical side effects from the disease or treatments such as pain and swelling of the legs, feat, arms and hands together with joint and muscle pains causing discomfort indicating the importance of implementing views to nature as a natural pain distraction easing the pain experiences.

The building layout should be focused on emphasizing the connection to the green recreational area bounding the site to the North creating several possibilities for access encouraging the use P a g e 28 | 62

of it. Additionally, the view of nature should be provided in most rooms increasing the soothing effect of the surrounding nature.

3.3.2.4.Personal and Social Space The discussion about privacy and sociality in relation to healing architecture mainly focuses on hospital wards being designed with single or multi bed rooms. In relation to the cancer center it is, however, relevant to understand the importance of privacy and confidentiality as well as social interactions. Personal space describes the privacy a patient and the relatives can feel within a health care facility, either because it is physically bounded by walls or because it is a space, where one can be alone, where one can be in control and keep ones belongings.

The possibility for privacy is important in order to build up a confidential, faithful relationship between the patient, the relatives and staff. Additionally, the social relationship between a patient and the relatives plays an important role in the healing of the patient, as well as in the recovery of the whole family. As mentioned in the section of acoustics, privacy in relation to consultation and counseling is of high importance, as many patients withhold information, if they feel others can hear them. It can likewise cause distress to hear others’ personal conversations and to gain unwanted medical information which may also apply for oneself.

Social space describes the communication and social interactions within a health care environment between patients, relatives and staff. For the relationship between the patient and the relatives to be optimal, the health care settings need to provide private spaces for the family to be alone together and to do everyday things together. Social interactions among the patients have proven to be important, as conversation with others in the same situation can help reduce stress, anxiety and fear.

It has further been proved through research, that social interactions involving social activities such as cooking and dining have had a great impact on patients’ energy level and healing process.

Relations between the staff and the patients are important, as the staff can help reduce anxiety and stress among the patients. It has been concluded that it is of high importance to the patients, that they can easily get in touch with the staff and that they seem present and available.

The planning and the interior decoration are important in relation to optimize the health care settings for privacy as well as social interactions. It is important to create spaces for people to be private, facilities, where they can keep their belongings and spaces, where they feel a bit in control. Private spaces also comprise spaces to be alone with one’s relatives or closest friends.

Furthermore it is important to create common spaces for social interactions, for smaller or larger groups. The common spaces should reflect and accommodate everyday activities, as these are easy to access and take part in even if people are unfamiliar with each other. Also casual arrangements with movable furniture, carpets and an overall homey atmosphere seem to foster social interactions in a positive manner.

3.3.2.5.Indoor climate The indoor climate, comprising thermal as well as atmospheric conditions, has a great impact on the wellbeing and comfort as well as the experience of a building.

It is poorly dealt with within evidence based design and healing architecture, but it is stated, that it is of high importance. Furthermore it seems likely, that poor indoor climate conditions would P a g e 29 | 62

interfere with the effect of the other evidence based design factors, as one cannot turn off the senses and would feel uncomfortable in the wrong conditions no matter the qualities of other architectural factors.

Unfortunate indoor conditions, such as uncomfortably high or low temperatures or bad air quality can affect work performances, mood as well as the physical wellbeing.

This is of even further importance, when dealing with cancer diagnosed people, who as a result of their disease already suffer from multiple conditions. For this reason, the cancer center should provide a healthy, comfortable indoor climate, why the indoor climate category A is chosen as a design demand, as it is the highest and most qualitative, and the ventilation rates are based on the CO2- pollution in the different rooms, giving a more precise estimate of the need for ventilation in regards of the activity, occupation and room volume of the particular room.

3.3.3. Evidence based design factors in the cancer center Cancer patients suffer from side effects from the cancer disease and the treatment, and the conditions are psychological as well as physical comprising stress, fatigue, depression, pain and anxiety.

It is found highly relevant that the cancer center is designed so it can relieve these conditions and help the patients in their healing and recovery from their disease.

Evidence from different research within healing architecture proves certain architectural elements’ effect on health care outcomes. The factors of light, acoustics, and relations to nature flow, personal and social space as well as a qualitative indoor climate are important in relation to the cancer center, as they have proven to relieve and decrease conditions like those experienced by cancer patients.

From the analysis of the factors some design parameters are listed forming the base for the design process.

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Views and access to nature relieves stress and pain.

Good daylight quality, min. 500 lux, creates a good working environment.

High intensity light, 2500 lux for 2 hours, relives depression and fatigue.

Clear plan, visible entrance and good overview makes the place inviting and manageable, reducing stress and anxiety.

Private space improves confidentiality and relieves stress and anxiety.

Social space improves social interactions among patients, families and staff, relieving stress, anxiety and depression.

Low internal noise level improves confidentiality and private spaces, reducing stress.

Low noise levels from exterior sources reduces stress and anxiety.

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4. Chapter four: case studies 4.1. Cancer center welfare home and research institute, Kolkata Introduction It is the only Indian Cancer Hospital to boast of a sprawling 16 acres of land with trees, gardens and water bodies that create an ambience of being cared for in the lap of nature.

The basic philosophy of such extensive natural landscaping is to blend nature, art, and architecture, with modern machinery, extensive medical know-how and tender loving care to soothe the agony of the thousands of patients, who come to us every year for relief from a medical menace called Cancer.

Location The hospital is located in Thakurpukur, Kolkata.

Key stats Land Area: 14.76 Acres Floor Area: 15380.67 Ground Coverage: 20% No. of Beds: 280

O.P.D 1.

Administrative and wards 2.

Information kiosk, doctor’s residence and patient kitchen 3.

Electrical substation 4.

O.T complex / surgical wards and diagnostic labs 5.

Bank and c.s.d 6.

Brachy therapy and children’s ward 7.

Patient’s cabins 8.

Radiotherapy and nuclear medicines 9.

C.T scan and special cabins 10.

Linac building 11.

Nursing complex 12.

Social rehabilitation and occupational therapy unit 13.

Jalan block 14.

Auditorium, library and cafeteria block 15.

Cottage of peace 16.

Toy train station 17.

Bridge 18.

Child care center 19.

In patient department – child care 20.

Pet C.T scan 21.

Parent’s quarter 22.

Amphitheater and toy train tunnel 23.

Oxidation pond 24.

Children’s park

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Building Typology and user flow

Building Plan Analysis

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4.2.

Tata medical center , kolkata

Introduction The Tata Medical Center is located in Kolkata, India and was opened in 2008. The hospital was set up to cater to the increasing number of Cancer Patients in Eastern India. The hospital was set up in an area of 13.4 Acres.

The Hospital comprises of about 34000 Sq. M of floor space in the first phase with about 167 beds giving state of the art facilities. The final bed strength is envisioned to be 300 beds with 74000 sq. m of built space.

Land Area: 13.4 Acres Floor Area: 34,368 sq. m Ground Coverage: 30% No. of Beds: 167

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Building Typology and User flow

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4.3.

Shirdi sai baba cancer hospital, manipal

Shirdi Sai Baba Cancer Hospital and Research Center, affiliated to Kasturba Hospital Manipal, is a 280-bed hospital dedicated to cancer care. It was commissioned in 1992 with generous financial assistance from the Shamdasani Foundation, with an aim of providing quality care at affordable cost for cancer patients. It is run on a non-profit basis, and provides comprehensive cancer care including prevention, early detection, treatment and palliation. The center caters to patients from costal and interior Karnataka and the neighboring states of Goa and Kerala.

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Conclusion Areas

CCHWRI, Kolkata

TMC, Kolkata

SSBCH, Manipal

Site Area

14.76 Acres (20% Coverage)

13.4 Acres (30% Coverage)

2 Acres (50% Coverage)

Bed Capacity

280 Beds

167 Beds (Phase I)

280 Beds

Parking

150 Cars

200 Cars

20 Cars

Recreational Features

There is a toy train for children to have a joy ride other than vast landscaped areas and ponds with fishes.

Vast Landscaped gardens

No landscape features

Out-Patient Department

1180 sq. m of OPD. The OPD is well lit and not airconditioned.

However is pleasant and no feeling of crowding. Since the treatment rooms are built around the large waiting space. No sense of confusion.

1173 Sq. m of OPD with ample treatment rooms. The corridors can be a little confusing and may add to the anxiety of patients.

291 sq. m of OPD. The waiting period is quite long for patients.

The ward to OPD size ratio is very different from other case studies.

Suggesting more long term patients rather than short term.

Diagnostic Facilities

Multiple Conventional Digital as well as Portable X Ray machines.

Portable & Conventional Ultrasonography and Color Doppler for superficial as well as deeper organs.

Mammography, Spiral Sub Second CT Scanner

Conventional Radiography, Fluoroscopy, Mammography, Ultrasonography with Color Doppler, CT Scan, .MRI Scan .64 slice PET-CT Scan, .SPECT-CT Scan

Again due to progressive growth has both obsolete as well as modern imaging facilities.

Dedicated CT scanner. Most imaging facilities are shared with KMC.

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Areas

CCHWRI, Kolkata

TMC, Kolkata

SSBCH, Manipal

Treatment Facilities

Cobalt Therapies, 3D CRT, Dual Energy Linear Accelerators, computerized Brachytherapy, Radio-Iodine therapy

Tomotherapy HiArt, Varian Novalis Tx linear accelerators, Intensity Modulated Radiotherapy (IMRT); Image Guided Radiotherapy (IGRT); stereotactic radiotherapy

Linear accelerator– Elekta Precise, Theratron 780C Cobalt Teletherapy unit, Nucletron’s Microselectron HDR

In-Patient Department

General Beds- 100 Children-40 Surgery- 20 ITU- 9 Semi Private- 91 Private-40 General Wards were crowded whereas other rooms had all the facilities to provide comfortable care.

Total Ward Space of 3318 Sq. M

General Beds- 52 Children- 20 Surgery- 10 ITU- 15 Semi Private- 28 Private- 42 State of the art wards and private rooms providing high standard of care.

Total Ward Space of 5074 Sq. M

General Beds-144 Children-20 ITU-12 Semi Private-48 Wards were sufficiently airy and had a good standard care.

Total Ward Space of 4617 sq. M.

Surgery/OTs

4 operation Theatres present which are state of the art and are equipped with all the modern facilities. The Surgical Floor is 677 sq. M.

8 Operation Theatres present on a highly efficient surgical flow layout. The total flood area of Sugary is 2546 Sq. M.

Shared with KMC Hospital.

Details unavailable.

Pharmacy

The pharmacy are distributed in the blocks.

There is a central pharmacy in the OPD department where is the store of the pharmacy is located in the basement.

Small Pharmacy of 20 sq. m located on ward floors.

Pathology

The central pathology laboratory occupies a space of about 361 sq. m and is adequate for the hospital.

The pathology laboratory occupies about 450 sq. m and is well equipped.

Pathology Lab shared with KMC.

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CCHWRI, Kolkata

TMC, Kolkata

SSBCH, Manipal

Target

Comments

No of Beds Per Acre of Land

18.9

12.46

140

15.46

Building Area/Bed

59.53

205.7

23.8

94.8

Recreation Spaces Percentage

17

25

Parking Spaces

150

200

50

400

Wards (percentage of Total Building Area)

33

20

43

30

Total Beds

280

167

280

310

8816 sq. m

General Beds

100

52

144

120

1975 sq. m

Children

40

20

20

35

460 sq. m

Surgery

20

10

20

375 sq. m

ITU

9

15

12

15

281 sq. m

Semi Private

91

28

48

65

1625 sq. m

Private

40

42

55

3500 sq. m

25

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CCHWRI, Kolkata

TMC, Kolkata

SSBCH, Manipal

Target

Administration

3.5%

3%

Imaging Facilities % of total building area

12%

10%

10%

15%

Radio-therapy % of total building area

7%

6%

10%

7.5%

Surgical Facilities % of total building area

5%

15%

Out Patient Department % of total building area

7%

7%

Services(% of Land Area)

1%

4.5%

3%

Pathology% of total building area

2.4%

3%

3%

Blood Bank(% of Building Area)

1.5%

1%

1.5%

Research(% of Building Area)

2%

3%

3%

Nurses Residences

9%

9.5%

9%

3.5%

15%

4.5%

7%

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4.4. The Cleveland Clinic Abu Dhabi Hospital Program: five clinic floors, three diagnostic and treatment levels, thirteen floors of critical and acute inpatient units, operational and support departments, retailers, a conference center, and a clinical simulation center.

Location: al maryah island, Abu Dhabi, uae.

Area: 248,433 m² Site area: 417,631 m² Outdoor area: 44,685 m² Parking lots: 161,507 m² Number of users: 364 beds (expandable to 490).

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Concept Inspired by the ancient Middle Eastern towns, which have several alleyways and courtyards that encouraged travel between various locales. Therefore, the hospital was arranged as stacked blocks, bridges and walkways connecting them.

The three largest blocks will house the outpatient clinics, the diagnostic and treatment center, and the patient tower.

The patient tower is oriented to allow unobstructed views of the sea and natural daylight to stab the structure.

Zoning

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ICU

Typical Patient Floor

Site Criteria.

•

The selection of CCAD’s site is preferred as it overlooks the seafront and surrounded by several famous and interesting places such as the Tourist Club, Rosewood Abu Dhabi, Photo Island, Abu Dhabi Mall, and other popular places.

•

The hospital has access from three sides; the fourth side is the waterfront that is adding a great value to the land and gives opportunities for outdoor functions and activities.

•

The interface of the seafront with the Cleveland Clinic Abu Dhabi site functions as an important transition from the hospital environment to a public waterfront space. Plazalevel café programming with outdoor seating provides useful access to the seafront for hospital patients, visitors and staff.

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4.5. Rush University Medical Center Program: hospital consists of 386 patient beds, with diagnostic and treatment facilities such as surgery, radiology and emergency departments.

Location: Chicago, IL, usa.

Area: 252,984 m² Status: completed 2012.

Users: 386 patients.

Concept The concept is based on creating a new continuous interventional platform. Part of the ground level of this base contains an emergency department which has been designed to be an advanced emergency response center for the City of Chicago. The geometry of the bed tower maximizes views and natural light for patient rooms while also creating an environment for efficient and safe health care.

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Zoning The hospital consists of a rectangular seven-story base, containing new diagnostic and treatment facilities, topped by a five- story curvilinear bed tower.

Typical plan

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4.6.Spaulding Hospital Program: eight-story patient tower, three-story healing gym and pool.

Architects: perkins + will.

Location: Charlestown, Boston, Massachusetts, united states.

Area: 35.150 m² Completed: 2013.

Concept The building is a new gathering place for the community offering 75 percent of the first floor to public use and integrating with the Boston Harbor Walk.

The landscape design integrates broken timbers throughout the site and takes full advantage of waterfront views of the Boston skyline.

A trail running along the waterfront features therapeutic equipment and offers patients the opportunity to encourage the healing process by performing physical therapy on a variety of different landscaped surfaces.

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5.

Chapter five: design strategy Provide single-bed rooms in almost all situations. Adaptable- acuity single-bed rooms should be widely adopted. Single rooms have been shown to lower hospital-induced nosocomial infections, reduce room transfers and associated medical errors, greatly lessen noise, improve patient confidentiality and privacy, facilitate social support by families, improve staff communication to patients, and increase patients’ overall satisfaction with health care.

New hospitals should be much quieter to reduce stress and improve sleep and other outcomes. Noise levels will be substantially lowered by the following combination of environmental interventions: providing single-bed rooms, installing high-performance soundabsorbing ceilings, and eliminating noise sources (for example, using noiseless paging).

Provide patients stress reducing views of nature and other positive distractions.

Develop way-finding systems that allow users, and particularly outpatients and visitors, to find their way efficiently and with little stress.

Improve ventilation through the use of improved filters, attention to appropriate pressurization, and special vigilance during construction.

Improve lighting, especially access to natural lighting and full-spectrum lighting.

Design ward layouts and nurses’ stations to reduce staff walking and fatigue increase patient care time, and support staff activities such as medication supply, communication, charting, and respite from stress.

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5.1.Program 



Buildable area o Inpatient Clinic o Outpatient Clinic o Administration o Research Center o Recreation o Amenities Unbuildable area o Activity area o Landscape o Parking

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







Administration o Entrance Hall o Waiting are o Offices o Meeting room o Lounge o Director office o Secretary office Outpatient Clinic o Entrance Hall o Clinics o Admission o Pharmacy o Waiting area Inpatient Clinic o Nuclear Medicine Department o Radiation Therapy Department o Surgery Suite o Chemotherapy Treatment o Intensive Care Unit o Special Oncology Unit o Pediatric Oncology Unit o Female Oncology Unit o Male Oncology Unit o Central Pharmacy o Laboratory o Imaging Unit o Biomedical Eng. o Central stuff facilities Research Center o Library o Work space o Offices o Reception o Administration o Laboratory o Service room o Storage o Kitchenette

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





Recreation Area o Pool o Gym o Playground o Coach office o Changing room o Events hall o Kids Area Amenities o Café o Restaurant o Storage & Cleaning area o Prayer halls o Satellite kitchen o Conference hall

Space Program o Inpatient Clinic 47% o Outpatient Clinic 7 % o Research Center 7% o Administration 4% o Recreation 10% o Amenities 5% o Services 20%

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5.2. Site criteria It is preferred to locate the project on a costal line.

The surrounded views are very important and should be considered while designing.

There should be a focus on the entertainment part of the project.

The surrounded environment that offers the highest levels of comfort and relaxation in the space is affecting the healing process in a positive way.

Interior design of the spaces has a major impact on the patients’ psychology and the whole healing process.

Relation between spaces indoor and outdoor should be clear for patients, doctors, and visitors to ensure comfortable and easy access for all.

Future expansion should be considered as the number of patients that are suffering from cancer is increasing every year.

Integrating the public community in the cancer center will prevent patients from being detached from the community so that they don’t feel strange after finishing treatment and go back to their normal life.

The accessibility for ambulances should be clear and easy accessed.

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5.3. Site suggestion

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Notre Dame de Secours Hospital – Byblos

Site suggestion

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http://phaidonatlas.com/building/rush-university- medical-center-new-hospital-tower/415511

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http://www.healthcaredesignmagazine.com/article/family-focus- incorporating-familypatient-room-part-3

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http://phaidonatlas.com/building/spaulding-rehabilitation- hospital/41561

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https://beta.dosomething.org/facts/11-facts-about-cancer

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http://www.archdaily.com/?p=292167

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http://www.riverviewmedicalcenter.com/RMC/services/cancercenter/AdvancedTechnologyto TreatCancer.cfm

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