MANIFESTO XXXVIII “To heal, an environment to thrive must be created.”
Kerri Clayton Arizona State University The Design School Environmental Design EDS 401: Design Synthesis Fall 2018 Nick Shekerjian
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CONTENTS Introduction: “Redefining a Hopsital to Functional Effeciency.”
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Antithesis 1: “Without function there is no 7 resaon to be present.” Thesis 1: “Let your moments there, be worthwhile.”
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Case Study 1: “Patient Preferences for Hos- 17 pital Quality: Case Study of Iran” Synthesis 1: “Become the place everyone needs you to be.”
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Antithesis 2: “Create a world outside your 25 boundaries.” Thesis 2: “Be in a place where you can grow”
Synthesis 3: “Internally the same, function- 57 ing in balance.” Antithesis 4: “Who will outsmart the other first?”
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Thesis 4: “We control the change.”
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73 Case Study 4: “Open Architecture for Healthcare: Case Study of Hospital Change in Practice” Synthesis 4: “Design, Adapt, Grow, Fucn- 77 tion.” Conclusion: “Healing Spaces and the Out- 81 side World”
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33 Case Study 2: “Hospital outdoor spaces: Therapeutic benefits and design considerations” Synthesis 2: “The outside gives us a per- 37 spective from within us” Antithesis 3: “From the inside: make it bettter.”
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Thesis 3: “Comfort is home.”
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Case Study 3: “Assessing Quality Design of 53 Interiors: A case study of a Hospital Outpatient Unit in Malaysia”
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“Redefining a Hospital to Functional Effeciency”
General Hospital of Niger,Ground Floor Plan of the Emergency Building
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The extent of a patients stays and care in a hospital are defined by the functionality of the space surrounding them, by redefining the space according to architecture and design it will bring a more efficient facility with better access to the needs of the patient. It is important to be able to care for people in the way that will most benefit them and we know that “the hospital as a type is not about to disappear anytime soon” (Verderber). The earth’s population is continuously growing, faster then hospitals can be built and with the expansion of people also comes the expansion of technology. When a hospital is able to meet both the requirements of the people
and technology is will be a functional utopia. There needs to be an improvement in the architecture of a hospital to ensure that all needs can be met in the best manner for the people inside the building. Medicine is constantly changing which means the machines in the hospital are always in rotation so the flexibility of the hospital has to be able to be up to par with the needs of its patients. Without a functional space the hospital itself will not be able to adapt correctly and not provide proper care, but if the building is designed knowing that it will constantly need to be in motion these problems can be avoided, simply. When parts are moving poetically and seams are flawless there is less chaos to be seen. Gene Klow1 stated “if an aesthetic… makes the people feel good; the patients, the staff and the visitors; the better the healing and work process” (RMJM). The correlation has been proven, it now needs to be implemented in all hospitals for the best outcomes of the people involved everyday. Alex de Rijke, one of dRMM’s co-founders, believes that you must bring some pleasure to the people that are having the hardest time, whatever their reason for being in the hospital is, there needs to be simple pleasures, and refers to it as a “manifesto for healthy architecture.” That is where the idea that there are hospitals all over the world that have been functioning fine over the past decades comes into question but times are always changing and the “pressing question for us today seems to be whether we can use evidence-based principles to design or redesign hospitals to make them into places of healing” (Rijke). The architecture of the building does not only play to the attraction of getting people inside the building but also needs to be functional. Hundreds of peo-
1 Gene Klow is a celebrated architect with over thirty-five years’ experience in the design and construction of healthcare facilities. Klow, Gene. “Hospital Design: Intelligent Architecture Where It Matters Most.” RMJM, 19 Sept. 2018, www.rmjm.com/ hospital-design-intelligent-architecture-where-it-matters-most/.
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2 The Hisham A Alsager Cardiac Center, 2016 “The anatomic scheme of the heart and its mechanism within the whole human body was used for the design of the project,” AGi Architects explained. “The heart is the central muscle of the system, which pumps blood to nourish the rest of organs and cells within it.”
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ple walk through the halls hourly and there needs to be an efficient path to get from your point of entrance to your point of destination. Each floor of a hospital has a specific purpose whether you are there for that floors purpose or not you are in that space, so a new design will improve the layouts of the floors. The walls of the building can be designed to hide certain machinery and still create an easy access while artwork can distract from the eyesores and make the environment a less harsh place to be around. Interior design plays a crucial role in the functionality, not only in the fact that is has been proven with a happier environment the healing process is expedited but it can use dual functionality. The hospital itself needs to show a unified front from the outside to demonstrate its professionalism but the needs of each patient that enters the hospital are vastly different, whether it is a young child with cancer, or an older gentleman going for a yearly checkup so the interior design needs to fit the needs of everyone who enters. As a cardiac rehabilitation center should fit the needs of someone who is recovering from a heart problem, which a facility in Kuwait2, has paved the way for how to cater to the architectural needs of your patients. The unique design of their new cardiac center by the AGi Architects used the heart itself and its mechanism as their inspiration, “the heart is the central muscle of the system, which pumps blood to nourish the rest of organs and cells within it” as the middle of the facility is a central space and then the patients pass through the building like a red blood cell would into the corridors that will best fit their needs (Griffiths). As described in Calvino’s, “Six Memos for the Next Millennium” exactitude, “means three things above all: (1) a well-defined and well-calculated plan for
the work in question; (2) an evocation of clear, incisive, memorable visual images; in Italian we have an adjective that doesn’t exist in English; (3) a language as precise as possible both in choice of words and in expression of the subtleties of thought and imagination� (55-56). A hospital needs to meet all three things stated and if they fail to do so then they will not be functionally efficient as the architecture, interior design, and sustainability to be continuously changing with technology is key to success.
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ANTITHESIS 1 “Without function there is no reason to be present.” 7
reas there is no , n o ti c n fu Without
sent
e on to be pr
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1 Joan Suchomel, AIA, a senior vice president with CannonDesign
2 Madsen, Deane. “How Modern Hospitals Recognize the Impact of Design on Health.” AIA, 2018, www. topicarchitecture.com/articles/154396-how-modern-hospitals-recog9 nize-the-impact-o.
“A functional design can promote skill, economy, conveniences, and comforts; a non-functional design can impede activities of all types, detract from quality of care, and raise costs to intolerable levels.” ... Hardy and Lammers The functionality of a hospital is what keeps their patients alive and their business afloat. But there has not always been one design for hospitals and every hospital entered has a different floorplan. But are they using the space to the best of their abilities and is the space that is being used efficiently occupied. Joan Suchomel1 redesigned the Christ Hospital Joint and Spine Center in Cincinnati and understood that to make the facility the best that it can be, and functional efficiently, it needs to show “experience and access, efficiency, flexibility, innovation, and brand”2. A hospital has many moving
parts that need to be accessible to everyone, but there needs to be a path where certain parts of the hospital can be avoided if needed. This makes the efficiency of the hospital equivalent to the efficiency that the doctors and the nurses need to work at. When everything is on the same level the functionality of the hospital cannot be denied and the retention of the patients and workers are at a maximum level, creating a better function hospital. Five goals3 must be met when designing a hospital to ensure that it will be a fully function, efficient, healthcare center and these goals include: (1) Patient-Centered – without patients there is no business (2) Efficient – the value of the hospital rises over time (3) Flexibility – adapting to the new technology as it evolves (4) Sustainable – it must be running 24 hours so keep low energy designs (5) Healing Environment – hospitals go beyond the medicine but also the art and pleasantness An efficient hospital is when the staff does not need to travel extensive distances to places frequently visited. If a space can be used for more then one purpose, then that space needs to be used in that manner as no space should go to waste in a high functioning hospital, this comes back to the idea of being flexible in the design plan. Anytime there is a group that will typically be there for the same reason that group should be confined, for example outpatient functions should be on the first floor since they will typically be the first to leave the building. An architects main focus when designing a hospital is planning from the inside out, as each room needs to have either one specific purpose or
3 Sprow, Richard. “Planning Hospitals of the Future” AIA. Accessed November 12, 2018. http://webcache.googleusercontent.com/search?q=cache:_ xRUWKuesH4J:www.perkinseastman.com/dynamic/ document/week/asset/download/3411781/3411781. pdf+&cd=10&hl=en&ct=clnk&gl=us&client=safari.
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multiple and once the rooms start coming together in the design the wings can be made and the rest of the building will follow. “Whether it is a large academic medical center or a smaller community hospital or rural healthcare facility, the form of a hospital needs to derive from the functional relationships which are essential to the efficient operation of a very specific 24 hours/ 365-day service, with overlapping functional needs�- Richard Sprow, AIA3. Dr. Richard Sprow, 2016
A hospital is the only organization that needs to meet these needs, and it is most likely the highest functioning part of each community. A hospital is under strict guidelines to make sure that the input of the people inside the building are able to operation all hours of the day and night to serve the people of the community.
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Johns Hopkins Hospital – Baltimore, Maryland
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Make the stay,
Be worthwhile.
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THESIS 1
“Make the stay, be worthwhile.”
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1 the manager of research and analytics at the Center for Health and the Social Sciences at the University of Chicago
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Changes can be simple, or they can create more problems before they are fixed. The functionality of a hospital can be a simple task like changing some desks around and creating space for new functions, or they can be difficult and create more troubles for the hospital. The designers job is to make these changes without problems arising, which means that there needs to be a solution for all possible reasons to be causing the problems. It is important to the patients that their time in the hospital is not wasted doing meaningless tasks. The doctor and nurses job is to make sure they are there for the right reasons and are efficient in their care. The best way to solve this problem is by using specialized wings in the hospital, and it is the most cost efficient way to solve this problem. Thomas J Best1 explains the benefits, “The more a wing specializes, the more a hospital
can take advantages of focused care; quality, costs, and lengths-of-stay may all improve�2 but there is a risk the hospital needs to be willing to take if they go with this approach because it may create a difficulty placing the patients in the necessary wings, without an overlap in treatment plan. If there is an admittance to the hospital that means there is a reason you will be staying there whether it is an hour or multiple months, but whatever the reason is the hospital needs to be able to accommodate whatever you need. With advances in technology and medicine there has been a steady decline on the typical amount of time someone must spent in the hospital after they have been checked in. With the redesign of hospitals that have been going on over the past few years, there has been a primary focus on making sure that the rooms are private and can have a sense of home. While they do look nice from the outside are they still providing all the care that a patient staying for a while may need? Do they have access to the outside world if the patient is very immobile? Or are they just there to show off the new design? The functionality is in the hands of the hospital and it is important to make sure they are creating an enjoyable and functional stay the directors of the hospitals must prepare in the best way forward to enhance these crucial factors.
2 “Four Ways to Make Hospitals More Efficient.� Chicago Booth Review. August 17, 2017. Accessed November 15, 2018. http://review.chicagobooth. edu/magazine/spring-2016/ four-ways-to-make-hospitalsmore-efficient.
Functionality - the quality of being suited to serve a purpose well; practicality.
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CASE STUDY 1 “Patient Preferences for Hospital Quality: Case Study of Iran” 17
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1 Jouyani, Y., Bahrampour, M., Barouni, M., & Dehnavieh, R. (2013). Patient preferences for hospital quality: case study of iran. Iranian Red Crescent medical journal, 15(9), 804-8.
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The Ministry of Health places a high priority on the importance and uniqueness of the characteristic of the health sector, and measures the efficiency and quality of service, “which are provided for the people who refer to the health sector1�. This study stepped back and took a look at the features that the patients are given from the eyes of the patients. The quality of the hospitals that the patients enter are of extreme importance to make sure that their needs and wishes are taken care of. Three hundred and thirty patients from the Imam Khomeini hospital, which is in Iran filled out a questionnaire to collect data in a cross-sectional study. From this study and research it was found that, “determination of the marginal utility characteristics shows that the first priority in receiving hospital services is the type of exam-
ination”2, meaning that when patients enter into the hospital they do not want to be tested many times to try and figure out what is wrong with them but instead would like a clear idea from the beginning. Doctors began to place a stress on not wasting the patients’ money, time and resources to make sure that they are functioning at a high rate but still doing their job to the best of their ability. Also found in the case study was, “the last priority in the cleaning service of the sections and restrooms.” There is always placed on a high importance by the hospital itself to be clean, because they can not risk a patient’s health declining because of something they could have controlled but the study showed that patients are least worried about the cleanliness of the sections and restroom, which could be because they trust that the hospital will already be concerned about those sections. The hospital functionality must be at a high if they do not want a negative impact on patient preference3.
2 estimating the utility function the software STATA version 10 was applied
3 “Waiting time between hospital arrivals and admission has a negative sign which indicates a negative impact on patient preference”
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SYNTHESIS 1 “Become the place that everyone needs you to be.” 21
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It has never been thought that a hospital does not function to the best of their ability, because if that was the case the hospital would not remain in business for very long. With that being said, who can decide that how the hospital is functioning at the time is the best that it can function. Unless the hospital was built within the last ten years the chances are that it can be designed in a way that can better handle the pressure to be innovative and adapt better then it needed to previously. A hospital can only be changed so many times from its original form before it starts become more of a problem to change the building then the reason for changing the building. The jobs of the people inside the hospital will never change, even though everything around them is changing which is why it is important that the doctors, nurses, technicians, and everyone else involved in the workplace do not have other worries then the safety of
their patients that day. From the studies shown in how to improve the efficiency in the hospital it is never how the patients act that can directly change the efficiency but if their time is respected they tend to react to the hospital better. When a patient feels respected there is no longer the original hostility between the patient and the doctor which makes the doctor able to focus on the task at hand and get the work done that needs to be done. There will always be pressure to be that best that people ask of you but if your building does not fit the need of what you need to accomplish then the disadvantage will always out way the work that can be done. The new design of the hospital will allow the patients and doctors to move through the building, and be able to grow in their work and their rehabilitation to get better. This is the main focus and by having such a strong focus on the efficiency of the hospital the functionality will be matched and there will be no room for error.
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ANTITHESIS 2 “Create a world outside your boundaries.” 25
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d orl
outside your boundaries.
aw
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“The “ambiance” of a space has an effect on people using the space” –Marc Schweitzer
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The environment once entering the hospital has started to shift recently into including parts of the outside world to reduce the stress and anxiety of the patients and enhance their health and healing. Even just having a window to see the outside world can increase the patient’s health but when bringing life into the building it can be a livelier setting. Dr. Charles R. Hall, Ellison Chair in International Floriculture, Texas A&M University says: “Shrubs, trees, and flowers have a practical application in hospitals: the presence of plants in patient recovery rooms greatly reduces the time necessary to heal. The soothing effects of ornamental flowers and plants are so great that simply having daily views of flowers and other ornamental plants in landscaped
areas outside patient recovery room significantly speed up recovery time.”1 It is important that these elements of a hospital are not forgotten as being less important to the design. Architects can build their ideas around the concept of bringing the outside world in, and a good use of this is to have open courtyards throughout the layout of the blueprint to ensure that natural light and appearance can be seen throughout. “The design elements with the most beneficial environmental effects on the health and well-being of people in healthcare facilities are: single-bed patient rooms with private toilets, safe and easily cleanable surface materials, sound-absorbing ceiling tiles, adequate and sufficient ventilation, thermal comfort, control over temperature and lighting, natural daylight, views from windows, access to nature, and appropriate equipment and furniture in the patient room.” A hospital always needs to remain healthy and clean and having greenery in the hospital naturally helps enhance that. Alexis Rochester, a Chemist, has agreed that “plants have so many intricate chemical processes going on constantly, and they are amazing in dozens of ways. Plants remove multiple toxins from the air, including carbon dioxide, carbon monoxide, formaldehyde, and even benzene.”2 These elements in the air are not something that can be vacuumed up so having the plants inside is continuously being beneficial to the hospital.
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Be in a place where you can
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grow
THESIS 2
“Be in a place where you can grow.”
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“Having these in the entrance of a healthcare facility will allow for a seamless transition from the outdoors to the indoors� It does not take long for the outdoor elements to effect your body; all it takes is a couple minutes. Imagine you are in charge of designing one of the most important buildings in our lives, a hospital, and with a simple plant you can increase a patients healing and recovery time that seems like it would be a no brainer. Doing good for the community does good for everyone involved which is why hospitals should not only want the implementation of the greenery but also the desire to make that change.
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When creating something to be proud of there are many steps that can achieve that goal but to create something
that not only hits all targets of architecture, design, adaptability, and sustainability to meet the goal of being a high functioning and efficient hospital is where the design needs to be. “design considerations that may contribute to achieving a healing environment with positive effects on patients’ well-being and outcomes of their medical treatments, while simultaneously raising the overall hospital’s efficiency” It has been proven that nature promotes healing. Ulrich1 and his team from Uppsala University of landscapes in Sweden, in 1993, “randomly assigned 160 heart surgery patients in the intensive care unit to one of six conditions: simulated “window views” of a large nature photograph (an open, tree-lined stream or a shadowy forest scene); one of two abstract paintings; a white panel; or a blank wall. Surveys afterward confirmed that patients assigned the water and tree scene were less anxious and needed fewer doses of strong pain medicine than those who looked at the darker forest photograph, abstract art or no pictures at all”2. If the hospital at the time does not have the means to place real plants and flowers, then they can take the next step and place artificial objects in the room to better the chances of survival.
1 Roger Ulrich is an environmental psychologist at Texas A&M University 2 Franklin, Deborah. “How Hospital Gardens Help Patients Heal.” Scientific American. March 01, 2012. Accessed November 17, 2018. https:// www.scientificamerican.com/ article/nature-that-nurtures/.
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CASE STUDY 2 “Hospital outdoor spaces: Therapeutic benefits and design considerations” 33
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1 Nedučin, Dejana & Krklješ, Milena & Kurtović-Folić, Nađa. (2010). Hospital outdoor spaces: Therapeutic benefits and design considerations. Facta universitatis - series: Architecture and Civil Engineering. 8. 293-305. 10.2298/FUACE1003293N. 35 36
The architecture of hospitals has always placed an importance on the outdoor living healing aspects to the patients in a positive manner. The economy and the poor state it was in over the last decade put a strain on the focus of making the surroundings positive and supportive to the people entering the building. “With the aim to reduce costs of medical therapies without sacrificing their quality, this new approach resulted in a substantial shift in planning and designing of both indoor and outdoor hospital spaces.”1 This study was instrumental in proposing what could be done to change the design of the spaces to be a better functioning hospital from the outdoor space perspective, while “simultaneously raising the overall hospital’s efficiency”. A stay in the hospital is already unpleasant because of the reason
that the patient is in the building so by examining features and elements to assist making the stay be more enjoyable, supportive, inviting, secure, and non-threatening so the case study shows how those can be achieved while taking away all negative assumptions that may be thought about from a patient standpoint on hospitals in general. The importance of an outdoor space is “they should be planned according to following requirements: (1) to create opportunities for movement and exercise; (2) to offer a choice between social interaction and solitude; (3) to provide both direct and indirect contacts with nature and other positive distractions�2. From past studies it was shown that the most important part of a patients stay was based on the economical and medical benefits but recently there has been a shift and it has shown from more studies that patients experience positive health outcomes from connection to the natural world outside and their access to fresh air, if possible, landscape views, and natural light.
2 Ulrich, R.S.: Effects of Gardens on Health Outcomes: Theory and Research, in Cooper-Marcus, C., Bar-nes, M. (Eds.): Healing Gardens: Therapeutic Benefits and Design Recommendations, John Wiley & Sons, New York, 1999, pp. 2786
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SYNTHESIS 2 “The outside gives us a perspective from within us.” 37
The outside world gives us a perscpective from within
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Khoo Teck Puat Hospital of Singapore, 2018
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The design of the building will be taller rather then longer making the space outside minimal. The landscape architecture will range from tall trees to colorful flowers and pathways will be placed throughout so that it can be an interactive setting. There will be gaps in the floor plan so that aspects of the outside world can be placed throughout making the indoor outdoor feel seamless. This idea is not presented in hospital often because until recently there was not an expected need for the patients to have the such positive benefits from outdoor elements. It is not just for the look of the building, which does help with revenue and other financial benefits but the main purpose of the hospital, the patients, is blossoming. Sick Building Syndrome (SBS) is the term that describes the adverse health and feelings of discomfort an
individual may experience when spending an extended amount of time in the same building (such as their place of work). For this reason, both hospital patients and employees are at risk of developing Sick Building Syndrome.1 It has been proven that having flowers in the room of patients reduces their levels of stress more than patients that do not have flowers in their rooms. It is not plausible to expect to place fresh flowers in the rooms every day which is why the outside windows of the buildings can have flower holders where the patient will be able to see, have access to, and touch the flowers but this is a more sustainable solution to the reduction of stress.
1 Rochester, Alexis. “The Benefits of Plants in Hospitals.” Stunning Range Of Plants For The Office & Outdoor. Accessed November 17, 2018. https://www.phsgreenleaf. co.uk/the-benefits-of-plantsin-hospitals/.
The whole goal in this part of the design is for the people. A hospital will not be able to function at all let alone at a high efficiency level if the people inside the building are not giving their best foot forward. Times are changing to quick to ignore the small details that designers can quickly change to improve the lives of the people around them and if something as small as putting as putting flowers in the walkway leading up to the hopsital, or a tree in the waiting room, can help the moral of a sick patients then that is on the designer to take the necessary steps to get there.
“a visual link between a hospital and the geography and geology of the area in which it is situated helped make the building less frightening, less remote.” 40
ANTITHESIS 3 “From the inside: make it better.”
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1 Vice President of Academic Affairs and Dean of the New York School of Interior Design
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Life can move at a rapid speed, with no idea what the direction is taking you, when you can get off the slope, or how long it will last. That is the typical experience when going to a hospital, there are the exceptions but a hospital is designed to handle chaos. People react to chaos in different ways, which means there needs to be a sense of calmness within the entering so that there are no unnecessary stresses. Recently, a new research method has come to light in terms of hospital interior design, called evidence-based design. To correctly use this method, one must collect research and data to create a space in the hospital that will enhance the chances of having the best outcome possible for the patient. Dr. Ellen Fisher1 has stated that, an environment designed using the principles of evidence-based design can improve the patient experience and enable patients to heal faster, and better. De-
sign elements such as a comfortable place for the family in the patient’s room, a sink in the room, control over lighting, temperature, and air flow, all assist in healing...The design of the physical environment also has a substantial impact on the caregivers through creating more efficient and productive work areas, better support in the patient rooms, and the proper design of settings to mitigate medical error”2. The evidence-based design-features that not only effect how the patient heals, the well-being, stability, and emotions, but also how efficient the workers, has changed the interior design of a hospital over the past few decades. There are strategies that can maximize the natural light that is allowed in but can also have a sustainable aspect that do not use toxic materials and are energy efficient, giving a clean indoor environment atmosphere. A positive environment and design can influence the patients’ recovery time without the use of doctors or medicine. Hospitals, or better yet the hospital rooms for that matter, that have a poor interior design have been proven to have a longer stay of the patient then a room with the contrary design. Interior design is to responsibly create space holistically and thoughtfully, with a passion to improve the quality of life and human experience which for a hospital is key triggers that must be hit to be able to function at its highest, and also prove to be beneficially to the patients. The interior design of a hospital does not only benefit the patients but also the staff who are working extremely long hours, a study showed that a good interior design helped the cleaning staff have better results. The functionality of the hospital depends on how things are run but also if the hospital is not clean there will be horrible responses to the functions happening within the walls, so the small
2 Bauer, Amber. “The Architecture of Recovery: Can Design Affect Your Health?” Cancer.Net. May 23, 2014. Accessed November 15, 2018. https://www.cancer. net/blog/2014-04/architecture-recovery-can-design-affect-your-health.
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3 Richard, Lucie. “An Analysis of the Adaptability of a Professional Development Program in Public Health: Results from the ALPS Study.” BMC Health Services Research 15, no. 233 (June 14, 2014). Accessed November 14, 2018. doi:DOI 10.1186/s12913-015-0903-3.
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details that can help those functions go a long way. The “demand for interior design services from the healthcare industry is expected to be high because of an anticipated increase in demand for facilities that will accommodate the aging population”3. The average life expectancy is currently rising, meaning that there will be more people who will enter a hospital, and the hospital needs to be able to accommodate these needs. The shift will most likely mean that the older end of the population will enter retirement homes, or even hospice which means that the interior design of these rooms are crucial to try and ease the pain of the suffering.
C. S. Mott Children’s Hospital Ann Arbor, Michigan, USA
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Comfort Is Home
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THESIS 3
“Comfort is Home.”
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Interior design plays a crucial role in the functionality of a hospital, but throwing some designs on the wall will not go the distance to make it beneficial. The question that always needs to be addressed is how can one feel most comfortable in a place that is built for the uncomfortable. It is a question as old as time, but as a designer there is an obligation to make sure that the clients needs are met and fulfilled. Architects have done research to prove that the placement of windows to bring in natural light where the families wait for their loved ones is a crucial part in the healing process. Architects and interior designers work seamlessly together on the design of a hospital because without the consideration of the other field there is a gap in the functionality of the design. A study was shown to prove the benefits of natural light where patients that have just received surgery are placed in rooms, one that has a lot of nat-
ural light coming through the window and one room where it is only illuminated from man-made light and the patients that were placed in room with natural light coming through healed faster. Each part of the hospital is designed depending of the purpose of the room, so in a teaching hospital in the labs where students are trying to learn there are energy-efficient lighting so they can accomplish their tasks, but in a family longue area is it designed to feel more at home so that the family does not feel the stress of the hospital. The facilities are expected to preform at the top of its ability and “healthcare designers are responsible for crafting environments that provide quantifiable improvements in organizational effectiveness and patient outcomes and satisfaction”1. The interior design does not only benefit the patient by aiding their healing process but just the design of the hospital needs to be up to par with the needs of the patient. If the patient falls their needs to be handrails for them to grab onto, or the pathways to the bathrooms needs to be designed to not be obstructed by unnecessary objects. The simple improvements do not add to the value of the hospital, although they can help, it does not go far enough to compete against the other healthcare facility, especially in a time where there needs to be a retention rate higher then the others to make a profit. The Atlantic2 states that, “mounting clinical evidence suggests that better design can improve patients’ health”3 the moral of the overall setting is raised, and from a medical standpoint that improves a patient’s recovery. Within a hospital there is chaos on an everyday basis but if you stick to an overall theme it calms down the overwhelming actions happening around which can also improve the functionality of the hospital. There is a fine line
1 VAEV, UNIKA. “10 Interior Design Tips for Healthcare Facilities.” Unikavaev. Accessed November 14, 2018. https:// unikavaev.com/blog/10-interior-design-tips-for-healthcare-facilities/.
2 Jain Malin, an interior decorator, who has first hand expeirnced the process that goes through getting treatment in a hopsital
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between creating a calming presence and ignoring the importance of interior design that a designer must go through prototyping to find. Different forms of the hospital have different functions and can be designed to best exemplify these functions, for instance a waiting room needs to be warm and inviting, while a surgical room needs to be clean, slick, and functioning.
Inside Duke Univerisity Cancer Clinic, 2018 51 52
Ann & Robert H. Lurie Children’s Hospital of Chicago, 2018
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CASE STUDY 3 “Assessing Quality Design of Interiors: A case study of a Hospital Outpatient Unit in Malaysia” 53
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1 Stage 1: Background information and design characteristics, gathered from Head of the Outpatient Unit and personnel. Drawings of the Unit layout were analyzed and diagramming drawn. Stage 2: Walkthrough observations were conducted for two-day duration, recorded using note pad and digital camera Stage 3: Feedback from patients and visitors was gathered using occupant survey form 55 56
An outpatient unit in Malaysia, conducted a study to understand the patients’ expectation, preferences, and experiences with the focus on the interior design characteristics. The data was collected in three stages1 and focused on interior design aspects like, “clustered as space planning, ergonomics, accessibility, way finding, material and finished, color, lighting, furniture, and safety.�2 The hospital in Malaysia was found to have decent standings in all categories from the survey but none of these aspects in the hospital were considered good. Different parts of the hospital were analyzed and critiqued so that positive changes could be made. The main entrance of the hospital was thought to not have enough color and needs that to be able to enhance the area since that is the first place that is entered in a hos-
pital. A consultation room was also analyzed and critiqued where the design was not up to par with what needs to be placed inside the room to be efficient. The study brought back a lot of information about the color on the walls but also the finishing on the floor. The Malaysia hospital had hardwood finishes on the floors which were said to “contribute to the noise in the area.” Because of the feedback from the patients where they only believed that the conditions and design were decent, Malaysia took it upon them to better the interior design of their hospitals to become a fully developed nation. Stage 1: Background information and design characteristics, gathered from Head of the Outpatient Unit and personnel. Drawings of the Unit layout were analyzed and diagramming drawn. Stage 2: Walkthrough observations were conducted for two days’ duration, recorded using note pad and digital camera. Stage 3: Feedback from patients and visitors was gathered using occupant survey form.
2 Abu Samah, Zanariah & Ibrahim, Norhati & Othman, Sajaratulnisah & Hanif Abd Wahab, Mohd. (2012). Assessing Quality Design of Interiors: A case study of a Hospital Outpatient Unit in Malaysia. Procedia - Social and Behavioral Sciences. 35. 245–252. 10.1016/j. sbspro.2012.02.085.
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SYNTHESIS 3 “Internally the same, functioning in balance.” 57
Internally the same, Functioning in balance.
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To create a healing environment within the hospital that does not put a stress on the patients is a key concept in hospital design. Architects have to work to create the space but then an interior designer put use the space given and create the most they can from the opportunities presented. Imagine walking into a hospital and seeing planters with dead flowers, paintings with dull colors, walls with unwelcoming paint, and dim lighting. The chances are that the moral of oneself will immediately go down just walking into that type of environment, which is why interior design is crucial in the final product of the hospital. Many of times it has been thought that these are expenses the hospital is not willing to make since it will be so expensive in the end with all the technology and equipment that goes into creating a hospital. This is where that is completely wrong and in the end will be so detrimental to
the state of the hospital that it would have been easier to spend the money in the front and have it pay dividends at the end of the day. Now imagine walking into the front doors of a hospital with enough windows so that the natural light is coming in, designs on the walls, paintings with bright colors, and aspects from the outdoor environment brought inside, like trees, plants, and flowers. The overall moral of the hospital is better which from studies has shown that the patients will have a shorter stay in the hospital since that is a natural aid to healing, meaning that more patients can be seen in the hospital and a higher revenue. The new design will use these aspects of interior design to better the hospital as a whole. What is referred to as a therapeutic environment1 will be a focus in the final product. A space that is specifically used for cancer treatment will have calming colors and lighting to relax a patient that is already going through a stressful time, and it has been shown that unneeded stress on the body2 will be counteractive to recovery and place the patient in the center for a longer time. A wing designed for children will be bright and vibrant with interaction, to mimic the way a child should be playin-g around and enjoying their life. When a design to better the life of a child in the hospital it also can better then parents of the child as they will be able to picture their child and happy and healing instead of sick and in bed. How the hospital looks on the inside reflects how a person should feel on the inside. There needs to be a balance between chaos and function to allow for the efficiency to remain up to par but also handle anything that is thrown it that direction. The balance is the most important part, because without it the spectrum will become so distorted, resulting in a poorly run establishment and a poor health.
1 A therapeutic environment refers to physical, social, and psychological safe spaces that are specifically designed to be healing. But most often, the term therapeutic environment refers to a physical space that is set up to allow individuals to work through and overcome medical issues.
2 There is growing evidence that light exposure—particularly at night—can directly affect parts of the brain that regulate mood and behavior
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ANTITHESIS 4 “Who will outsmart the other first?”
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Who will outsmart the other first?
1 Sprow, Richard. “Planning Hospitals of the Future� AIA. Accessed November 12, 2018. http://webcache.googleusercontent.com/search?q=cache:_ xRUWKuesH4J:www.perkinseastman.com/dynamic/ document/week/asset/download/3411781/3411781. pdf+&cd=10&hl=en&ct=clnk&gl=us&client=safari.
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The world around us is constantly changing, and if a change is not made before the surrounding changes then it is a disadvantage that must be overcome. A hospital can never be at a disadvantage, there is no time for that. The architects behind the design of a hospital need to be one step ahead of the advancements in healthcare, technology, and culture. A problem arises when the original plan of the hospital is not adaptable to change for the future advancements. The architect is then needed to go back to the original blueprint and create a space where there is no space currently available. In some countries, hospitals are created with the idea that it will need to be changed and shifted over the years meaning that they create a larger hospital then what is originally needed and can the shift in medicine and technology happens the building is also able to shift seamlessly.
“A hospital is an intensely people-centered building type in which efficient circulation and the flexibility to meet unknown future challenges are critical factors in how well it supports these operations.” - Richard Sprow, AIA1 A design must be created to have a purpose, good wayfinding, technologically sound, and an environment to heal but it can not be assumed that the room is going to remain the same purpose forever. Today, hospital rooms are less specified so that they can easily move patients around depending on where there is room for them but that cannot always be the easiest solution which is why a plan and design must always be in place. Harold Thimbleby2 explains, “technology does not have an agenda of helping healthcare,”3 the machines are specifically for healing someone but instead they are made so that it can lower the cost of a procedure and in turn an investment and interest will be made better benefitting the hospitals. Hospitals are run on the amount of money that can be made, so when an idea is presented that will make the most money it is taken and run with, and this is typically in the form of a technological advancement. The largest change has come from the implementation of electronic records. When the shift went from paper to computers it was able to transform spaces that are no longer wasted space but now somewhere that can be used for the people, this is all about the adaptability of the hospital and how well
2 Harold Thimbleby is a professor in the College of Science at Swansea University 3 Thimbleby, Harold. “Technology and the Future of Healthcare.” Journal of Public Health Research 2013 2, no. 28 (November 1, 2013). Accessed November 14, 2018. doi:10.3897/ bdj.1.e1005.figure2f.
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it can function. Once there is a change in healthcare, there is no going back, the changes do not reverse in healthcare meaning that the permanent design is one that needs to be flawless, a task for the architect to think about before construction starts. 4 Michael Hans, RN, is a professional development educator in the Department of Nursing Administration at St. Jude Children’s Research Hospital
“In health care, change is always in the air. How we adapt makes the difference.” –Michael Hans, RN4
Embracing change does not just stay to the design of the hospital, but if the worker knows that the hospital is always ready to adapt then the workers will also be able to adapt easily when the time comes. The care of the patients can only be as good as the people who are do the care, so when the workers are given the correct resources, the care can be unmatched. It all comes back to the main question, how can the hospital be adaptable and function at its highest efficiency rate. The biggest challenge is knowing when it is time to adapt or rebuild. There comes a time when no more changes can be made to the existing structure but how can a building be sustainable enough to adapt through generations of advancements.
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Fortis Memorial Research Institute – Gurgaon, India
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We
Control
The
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THESIS 4
“We control the change.”
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1 Richard, Lucie. “An Analysis of the Adaptability of a Professional Development Program in Public Health: Results from the ALPS Study.� BMC Health Services Research 15, no. 233 (June 14, 2014). Accessed November 14, 2018. doi:DOI 10.1186/s12913-015-0903-3.
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There are two types of adaptation (1) initial pre-formatting to accommodate organizational context (2) ongoing adaptation of implementation to take into account the needs and con- texts of the participants1. Alterations can not be denied and will always be part of the functionality of a hospital, but a plan must be set to handle these alterations. The first type (1) of adaptation is knowing that there will be a change and there is already a thought-out plan before and changes have been presented so that it will be altered seamlessly and the hospital can remain efficient. The second type (2) creates a plan as the alterations are presented, meaning that there is room to make the changes but the plans are not presented beforehand, it changes as the shifts happen. The new technological changes present many problems within the function of rooms, for instance, dialysis suites and pharmacies have to meet more rig-
orous standards then previously to ensure the safety of the patients, but it cannot just be done by moving some items around it takes a full redesign. It is a difficult task to understand exactly what will change and what will need to be done to change the rooms to make sure that the function is still high. Richard Sprow explains that, “in order to get maximum efficiency in the use of this space, the current best practice is to organize services in modular units, each of which has standardized waiting, reception, exam, consultation and office areas.”2 As of now that is the only solution that designers have come up with because this is such a prevalent issue in the 21st century but there is room for improvement always. In the history of hospital design, the different departments have always been completely cutoff from each other by separate wings, floors, or buildings but “to provide more flexibility and more efficiency of operations”3 there can be a connection between the departments and not have hard definitions of what is placed where once within the building.
2 Sprow, Richard. “Planning Hospitals of the Future” AIA. Accessed November 12, 2018. http://webcache.googleusercontent.com/search?q=cache:_ xRUWKuesH4J:www.perkinseastman.com/dynamic/ document/week/asset/download/3411781/3411781. pdf+&cd=10&hl=en&ct=clnk&gl=us&client=safari. 3
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Peter Cook, 2018.
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Bunrungrad International Hospital Bangkok, Thailand
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CASE STUDY 4 “Open Architecture for Healthcare: Case Study of Hospital Change in Practice” 73
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1 The open building theory distinct between levels of intervention in relations to the hierarchical structure of the built environment in which higher levels serve as the setting and context in which lower levels operate
2 Nirit, Putievsky Pilosof, and Kalay Yehuda E. “Open Architecture for Healthcare: Case Study of Hospital Change in Practice.” The 2010 International Conference on Advanced Technologies for Communications, 2010. Accessed November 14, 2018. doi:10.1109/atc.2010.5672702.
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The case study is developed on the fact that changes will always have to be made to hospitals and the building must be sustainable to be able to handle the design changes that come with new technology, advancements in medicine, and sociology. The open building theory1, “proposes a strategy to design hospitals for flexibility by system separation of the primary system “base building”, the secondary system “tenant fit-out”, and the tertiary system of “FF&E” (furnishings, fixtures and equipment).”2 When designing and planning hospitals there must be a method to handle the changes in flexibility, adaptability, and expansion that must be thought into the plans. In Israel, the Sammy Ofer Heart Building3 at the Tel Aviv Sourasky Medical Center4, used the open building theory and this case study focused
on the changed over time in that medical center and how they were affectively used. The research dives into the changes that caused design changes whether it was a medical advancement that needed to be added to the floorplan of the hospital, or a transformation in social healthcare norms, and how the standards of healthcare change with time. The hospital needs to be able to seamlessly change through these differences and the Sammy Ofer Heart Building was able to make these changes, proved through this research. There needs to be flexibility in design a hospital because it will need to be able to make changes through the building three stages, (1) design, (2) construction, (3) occupancy. The architects designed this building anticipating that there will be changes in medicine so the plan was made that some floors would be left empty so in the future it could be added when needed. When a hospital goes into a change phase there are five main categories: “time, type, cause, project phase, design state, and system level.� This case study proves that when building a hospital there must be a set design plan for sustainability, a long-term value within the facility, and an option for adaption is policy, medicine, technology, social transformation, and design.
3 Designed by Sharon Architects and Ranni Ziss Architects and was constructed in 2008-2011
4
Sammy Ofer Heart Building at the Tel Aviv Sourasky Medical Center
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SYNTHESIS 4 “Design, Adapt, Grow, Function.” 77
ngiseD tpadA worG noitcnuF
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1 Sprow, Richard. “Planning Hospitals of the Future” AIA. Accessed November 12, 2018. http://webcache.googleusercontent.com/search?q=cache:_ xRUWKuesH4J:www.perkinseastman.com/dynamic/ document/week/asset/download/3411781/3411781. pdf+&cd=10&hl=en&ct=clnk&gl=us&client=safari. 79
How important is it to the community that when they step foot into a hospital they know they will be getting the best care that is offered? Without being able to adapt and change to the new technological and medical advances that are being offered the people within the community will not be able to have the best care. Technology is not going to wait for a building to be ready for it to change, that is not the function of technology, which is why the building has to be ready before. The patient will always choose the hospital with the best care provided and “these innovative medical technologies help empower the physicians, nurses, and patients with tools that enable faster diagnosis and better treatment of disease”1. IT architecture is the art and science of designing and delivering valuable technology strategy.
IT architecture has implanted its way into a hospital setting by creating the maximum efficiency is providing doctors with information and data from the machinery and aiding in making a decision on treatment and medicine. “Flexible construction and planning for future renovation are most important in these diagnostic and treatment areas, where changing equipment needs and the frequent addition of new technology and new services require very specialized rooms to be adapted to house extremely costly equipment� –Richard Sprow Designers and architects cannot simply put a time frame on when the craze of technology is going to slow down but as new information is being discovered the technology will always be changing in search for the best possible care. Because that is the main focus for a scientist, doctor, or engineer, a main focus of a designer or architect is going to have to be on par with the counterpart and handle whatever is thrown at them.
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MANIFESTATION “Healing Spaces and the Outside World.”
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The design is to combine architecture and interior design to create a hospital that is not only highly efficient and functional but also can adapt with the changes in technology easily without affecting the health of the patients. The design will begin with the hospitals having extra floors already part of the architecture so when a change needs to be made there is already a plan in place. To compensate for all the extra space that will not be used during the periods that there are not advancements to make, the floors will be used to better the patients’ environment. Studies have shown that when elements of the outside world are present either by bringing them inside or just having the appears it increased the moral of hospital patients and in return increased their chance of recovery quicker. This design will not only allow for the hospital to be sustainable and adaptable but will allow for advancements to be made before the competition because the building will already be set for the changes. A hospital of this magnitude can be placed in any city as long as the city has the means for the hospital to be functioning. The design is based on the idea that the patients will be choosing this option over the competition but also that the hospital wants to be a top innovated building. A hospital is one of the most visited buildings in a city which means it is important that it not only looks good from the outside and presents a solid front to the city but can also handle the traffic that will come through the doors everyday. 82 83
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BIBLIOGRAPHY
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