Kamuzu Psychiatric Hospital Comprehensive Plan by Rachel Meier

Kamuzu Psychiatric Hospital Architectural Solutions for Compassionate Care Lilongwe, Malawi

KAMUZU PSYCHIATRIC HOSPITAL: ARCHITECTURAL SOLUTIONS FOR COMPASSIONATE CARE by Anna Ayik, Raymond Bracy, Rachel Meier

Project presented to the Faculty of the Department of Architecture College of Architecture and the Built Environment Thomas Jefferson University In partial fulfillment of the requirements for the degree of

BACHELOR OF ARCHITECTURE BACHELOR OF LANDSCAPE ARCHITECTURE Arch-508 / Design 10: Research and Design Faculty Associate Professor Chris Harnish Philadelphia, Pennsylvania May 2019

HOW CAN DESIGN AND

COMPASSIONATE CARE

REINFORCE ESTABLISHED CARE MODELS TO POSITIVELY IMPACT PATIENTS IN MALAWIâ&#x20AC;&#x2122;S PSYCHIATRIC HEALTHCARE SYSTEM?

STATEMENT OF INTENT The development of a comprehensive and replicable framework for a psychiatric hospital and grounds in Malawi, Africa will act as a standard for providing resources and education for patients in similar contexts. There will be a focus on exploring innovative ways to balance traditional beliefs about mental health with Western medical advances. The case study explored will be implemented into a previously developed 20-year master plan for Kamuzu Central Hospital in Lilongwe, Malawi to explore healing through building and landscape design.

WHO WE ARE As current architecture

and landscape architecture students at Thomas Jefferson University, we invite you to delve into the explorations of our final semester of studies. We understand that we are not experts, however, our intensive research process allowed us to make information-driven design decisions regarding a Psychiatric Hospital case study for Kamuzu Central Hospital in Malawi, Africa. The following pages establish the methods we used to study the history and current state of mental health care in both the world and the country of Malawi to produce spatial and legislative suggestions to the best of our knowledge and abilities. Thank you and enjoy, Anna Ayik, Raymond Bracy, and Rachel Meier

TABLE OF CONTENTS 6

INTRODUCTION

METHODS 35

CARE MODELS

COMPASSION

DESIGN RESEARCH

SPATIAL NEEDS

HOSPITAL DESIGN 89 103

SITE SELECTION WARD DESIGN

INTRODUCTION

WORLD HEALTH ORGANIZATION WORLD HEALTH SOUTHERN AFRICAN DEPEVELOPMENT COMMUNITY MALAWI MINISTRY OF HEALTH HEALTH SECTOR STRATEGIC PLAN

PROJECT THESIS

CARE MODELS

PROGRAMMATIC NEEDS

SPATIAL ADJACENCIES

DESIGN CONSIDERATIONS

SOUTHER DEPEVELOPME

MALAWI MINIS

HEALT STRAT

PR TH

CARE

PROGRAM

SPATIAL A

DESIGN CON

INTRODUCTION

PROJECT ABSTRACT

In the Sub-Saharan African context, 75-90% of people with mental illnesses do not have access to proper care and only 2% of health expenditures are allocated for mental health. The country of Malawi, in particular, recognizes up to 4,000,000 people with mental illnesses and has three formal facilities to care for them. Current facilities are challenged by over-crowding, a lack of training medical professionals, and the population distribution throughout the country. In addition to geographic and economic constraints, social stigmas decrease the number of Malawians willing to seek treatment. Even though most patients do not require long-term hospitalization, the need still exists to create facilities and legislation that set the standard for mental health education and compassionate care to reduce those stigmas. These standards and guidelines have not been present in either spatial or social terms over the last few decades, and establishing a strong environment for compassion and positive patient-staff interactions will only aid in the reduction of stress on the healthcare system. It is now an appropriate time to address the establishment of a replicable psychiatric care model in terms of both architecture and landscape architecture. Clear legislation to develop and evaluate mental health facilities is needed to regulate the quality of the facilities so that they remain open and function to the best of their abilities. 11

ORGANIZATION WORLD HEALTH ORGANIZATION

AFRICAN T COMMUNITY

RY OF HEALTH

ECTOR C PLAN

ECT IS

DELS

TIC NEEDS

ACENCIES

SIDERATIONS

SOUTHERN AFRICAN DEPEVELOPMENT COMMUNITY MALAWI MINISTRY OF HEALTH HEALTH SECTOR STRATEGIC PLAN

PROJECT THESIS

CARE MODELS

PROGRAMMATIC NEEDS

SPATIAL ADJACENCIES

DESIGN CONSIDERATIONS

INTRODUCTION

PROJECT ABSTRACT

An analysis of potential care models then becomes necessary to understand how the existing system can transform to meet growing needs in the mental healthcare sector. At the current moment, a small number of patients in Malawi are sent to the countryâ&#x20AC;&#x2122;s main mental hospital. Since this leaves many without access to care, the following care models must be discussed: traumainformed, housing-first, community-based, and an integrated medicine model. The integrated care model appears to be the most beneficial in encouraging people to seek treatment and will be studied in terms of potential physical design characteristics. A baseline set of programming for psychiatric care units in Malawi was presented to be amended and transformed through intense and thorough research. A series of discussions occurred with doctors and psychiatrists in the mental healthcare field in various countries to aid in the amendment of that programming. Proper care requirements were compiled to begin outlining adjacencies and programmatic needs that could potentially be applied to any appropriate context. These design elements and interventions answer the question of â&#x20AC;&#x153;how can design facilitate the mitigation of limited-resource psychiatric healthcare through compassionate care in Malawi?â&#x20AC;?

1% - DIABETES, DISEASES OF THE GENITOURINARY SYSTEM, OTHER NCDs 2% - TUBERCULOSIS, MATERNAL CONDITIONS, NUTRITIONAL DEFICIENCIES, CONGENITAL ABNORMALITIIES, MUSCULOSKELETAL DISEASES

13% - NEUROPSYCHIATRIC DISORDERS About 450 million people suffer from mental or behavioral disorder worldwide, leading to the highest percentage of years lost due to ill-health.

3% - SENSE ORGAN DISORDERS, MALARIA, DIGESTIVE DISEASES, CHILDHOOD DISEASES

12% - INJURIES

BURDEN OF DISEASES WORLDWIDE WORLD HEALTH ORGANIZATION (2003); INVESTING IN MENTAL HEALTH

10% - CARDIOVASCULAR DISEASES 4% - RESPIRATORY DISEASES, DIARRHOEAL DISEASES

7% - PERINATAL CONDITIONS

5% - MALIGNANT NEOPLASMS

6% - HIV/AIDS, RESPIRATORY INFECTIONS, OTHER CD CAUSES

INTRODUCTION

WHY MENTAL HEALTH? Mental illness has proven to be both a prevalent health and economic burden worldwide. The World Health Organization found that neuropsychiatric disorders cause the highest percentage of life years lost out of 22 disease categories#. The WHO also estimates that the global cost of mental illness will reach $6 trillion by the year 2030. This economic loss is much less due to the cost of care, but more so because of unemployment of people with mental illnesses, expenses for social supports, and additional costs for resulting chronic disabilities. Outlooks developed by the World Economic Fund find that mental illnesses will account for 35% of the global lost economic output. This figure can become even higher when it is taken into consideration that those with mental illnesses are at higher risk of cardiovascular disease, respiratory disease, and diabetes. Understanding the social and economic need for attention to mental health is vital in the coming years and decades of population growth.#

#. WHO (2003). Investing in Mental Health. Retrieved February 19, 2019, from https://www.who.int/mental_health/media/investing_mnh.pdf #. Insel, T. (2011, September 28). The Global Cost of Mental Illness. Retrieved February 17, 2019, from https://www.nimh.nih.gov/about/ directors/thomas-insel/blog/2011/the-global-cost-of-mental-illness.shtml

METHODS

QUANTITATIVE THESIS In Sub-Saharan African countries with resource disparities, 75-90% of people with mental illnesses do not have access to proper care and only 2% of health expenditures are allocated for mental health. With the recent closure of a psychiatric unit in Lilongwe, there are three mental hospital in Malawi: a 332 bed facility in Zomba, a 26 bed facility in Mzuzu, and a temporary, 50 bed facility in Lilongwe. These factors bring to light an immediate need for a new mental health facility in Malawi that can help serve the 16+ million people who live there.

LITERATURE REVIEW Given the research-based nature of this project, performing a literature review was essential to synthesize existing research into a set of conclusions. A series of scholarly articles, historic documents, interviews, and lectures were compiled on the topics of both design and psychiatric care. While these reviews can provide a wealth of information, distilling that which is most essential to the development of the design process is a key step. Once this step has been taken, conclusions can be drawn that will ensure the composition of qualitative and quantitative information-based decisions.

Child Psychiatrist in Berkeley, CA Spent 2 years at Queens in Blantyre with the Peace Corp Explained cultural stigma surrounding mental illness, spatial considerations Encouraged connection of indoor and outdoor programs

Dr. Jeff Almony

Child Psychiatrist in Broomfield, CO Went to Bangledesh for 7 year, spending a few weeks each year Introduced care model types, spatial considerations for a psychiatric ward

DOCTORS WE TALKED TO Dr. Jonathan Ngoma

INTERVIEWS METHODS

Dr. George Stewart

Head of Kamuzu Central Hospital Provided existing Bwaila Psychiatric Unit program

Dr. George Stewart

Dr. Jeff Almony

Child Psychiatrist in Broomfield, CO Went to Bangledesh for 7 year, spending a few weeks each year Introduced care model types, spatial considerations for a psychiatric ward

Dr. Jonathan Ngoma

Head of Kamuzu Central Hospital Provided existing Bwaila Psychiatric Unit program

Dr. Stephen Trzeciak

Intensivist, Professor & Chair of Cooper Medical School, Chief of Medicine at Cooper University Health Care Studied how compassion in medicine can help people heal

Dr. Kaitlan Baston

Medical Director of the Division of Addiction Medicine at Cooper University Hospital Encourages empathy in medicine Recognize, Align, Validate

Andrea Vettori, MSN, CRNP

Clinical Director of the Mary Howard Health Center for the Homeless Introduced the Social Determinants of Health, the rate of mental illness among the homeless, ACES and trauma informed care

Dr. Stephen Trzeciak

Intensivist, Professor & Chair of Cooper Medical School, Chief of Medicine at Cooper University Health Care Studied how compassion in medicine can help people heal

Dr. Kaitlan Baston

Medical Director of the Division of Addiction Medicine at Cooper University Hospital Encourages empathy in medicine Recognize, Align, Validate

In order to understand psychiatry and psychiatric care, two psychiatrists who have worked abroad in Malawi and Bangladesh were interviewed. The program of the old Bwaila Unit was received from Dr. Ngoma. While attending the 2019 Humanism in Medicine Conference at Thomas Jefferson University, Andrea Vettori, MSN, CRNP Clinical Director of the Mary Howard Health Center for the Homeless speakers emphasized a focus on compassion in medicine. Introduced the Social Determinants of Health, the rate of mental illness among the homeless, ACES and trauma informed care

HISTORY OF MENTAL HEALTH1 1910: Zomba Central

1930s: Start of belief

Prison opens its that mental illness “Lunatic Asylum” for the required treatment “mentally abnormal”; due to European mentally ill patients are influence; asylums are not allowed in hospitals still in poor conditions

1920s: Psychosocial

therapy begins in asylum, but sees no trained mental health workers and no improving facility conditions

1950s: Government

Medical Department initiates creation of Zomba Mental Hospital; psychiatrists and antipsychotic drugs are introduced

1943: Annex opens Zomba Central Prison to encourage occupational therapy for mentally ill patients rather than isolation in old wing

1960s: Mala

nurses are abroad to tra psychiatric nu order to build capacity and e other health w

awian sent ain as urses in service educate workers

psychiatric nurses are sent to district hospitals to run mental health services around the country

Hospital sends representatives to the Zomba District Health Office to spread influence; nurses visit prisons to assess and treat mentally ill inmates

1990s: Movement begins for community mental health with introduction of Mental Health Action Group (organization for development of policy, services and education)

2013: Zomba Mental

LITERATURE REVIEW METHODS

1980s: Locally trained

2017: Bwaila Psychiatric Unit closes after discovery of poor patient conditions; referred patients are sent to Zomba Mental Hospital four hours away by car

HOSPITAL MAP There are only 408 inpatient beds in a

country of 16+ million people3: 332 at Zomba Mental Hospital (in the southern district), 26 beds at St. John of God - Mzuzu Mental Hospital (in the northern district), and 50 beds at St. John of God - Lilongwe Mental Hospital (in the central district).4 In 2017, Bawaila Mental Hospital was closed because of poor conditions and a severe shortage of personnel. Zomba is the only public health facility and only facility that handles long-term care, although public care is provided at St. John of God Hospitals under a service level agreement5.

Mzuzu

St. John of God - 26 beds

Lilongwe

St. John of God - 50 beds (closed) Bwaila Psychiatric Unit

BED CAPACITY

Zomba

Zomba Mental Hospital 332 beds

Blantyre

Queen Elizabeth Hospital, outpatient

150%

Bwaila Psychiatric Hospital bed occupancy prior to closure2

LITERATURE REVIEW METHODS

The WHO estimate 25% of the worldâ&#x20AC;&#x2122;s population has a mental health disorder. Only half of those people with seek treatment in their lifetime. About 7% of patients with mental health disorders require hospitalization at some point and in Malawi, if the current inpatient facilities are full, only 18% will have access to a bed at any point in their life. This calculation does not account for readmission rates, which in Bwaila was about 7%.6,7

ACCESS TO CARE 25%

50% 7% 18% Pa Pa tie t o i Di p en en nt l h so e t P s os ts w 4 al op r w w de it pi m H u it 2 h h ill ea la t 1 r 2 i m o a 40 li io 5, n h A ill s w Me w n lth tio 2 ,0 ze io 00 life cc M n 00 d ill n ho nta al Di M tim es w n M M in e aw s al ith al se l H a o e aw e s t la lif aw e ia rd d ea o w ns e k e ia t ia i Be an tim o ns r ns he lth b s d lp e e

OVER THE NEXT TWO DECADES, MENTAL ILLNESSES WILL ACCOUNT FOR 35% OF GLOBAL ECONOMIC LOSS. INCREASED ATTENTION TO THIS ISSUE WILL DECREASE THE ECONOMIC BURDEN. INVESTING $1 IN TREATMENT LEADS TO A RETURN OF $4 IN BETTER HEALTH AND ABILITY OF WORK.

PERCEIVED CAUSES 34%

19%

12%

D W W ivin an itc ill e Po d S hcr of W ss pi aft G rat es rit od h si ua or on l s

LITERATURE REVIEW METHODS

In Malawi, the main perceived causes of mental illness are drug misuse, the divine wrath or will of God, and Witchcraft and Spiritual Possessions. These beliefs highlight the stigma that surrounds mental illnesses and the need to increase education of mental illnesses in Malawi.

35%

The most common mental illness that was seen in Bwalia Psychiatric Unit (inpatient) as well as in Zomba is schizophrenia, followed by cannabis use disorder, alcohol use disorder, and major depressive disorder.

PATIENT DIAGNOSIS 30%

28%

Di ab so is rd U er se

25%

Al c Di oho so l rd Us er e

10%

or Di De so pr rd es er siv e

Ill

PATIENT OUTCOMES 68%

St a Di bil sc ize ha d rg an ed d

20%

An Tra ot nsf he er r H re os d to pi ta l

M ha ed rg ic ed al A Ad ga vi in se st

LITERATURE REVIEW METHODS

Most patients who present in the mental hospital are stabilized and discharged from care. Some require a transfer to a better equipped facility as they require a longer stay. A smaller percentage are discharged against medical advice, absconded, or died during care.

Di de

Most patients with mental health issues do not need to be hospitalized because of their mental illness. Although, if hospitalized, there are short-term, acute wards for critical, immediate cases and long-term wards for chronic patients and anyone staying over 28 days.9

SEVERE

INPATIENT SHORT-TERM

INPATIENT LONG-TERM

MODERATE OUTPATIENT SHORT/LONG-TERM CARE

MILD

28 DAYS

93%

LITERATURE REVIEW METHODS

Patients will mental health problems do not always present at the psychiatric hospitals or clinics. 28% of patients in primary care settings in Malawi present with a common mental disorder while up to 40% of inpatients in Malawi hospitals present with comorbid depression to their physical illness. 10 These patients will benefit from an integrated medical model so they are provided psychiatric care in the main hospital.

OUTSIDE OF PSYCH HOSPITALS 28%

P pa rim m tie ar en n y c ta ts ar li w e lln ith es s

40%

I co npa m tie or n b t ill id s w ne m it ss en h ta l

PATIENT EDUCATION 4%

50%

40%

PATIENT SEX 72%

28%

W om

Un ar

Most patients that are admitted into the psychiatric hospitals have obtained some level of education. Mental health issues do not discriminate with education. Therefore, this leads us to believe that if more people are educated about mental illnesses, we can increase the number of people helped.

Lilongwe can help patients get the care they need when they are in a critical situation. It will also help outpatients adhere to their medication and therapy regimen to maintain their mental health and stay out of the hospital. There is a need for immediate intervention to help meet the demand of the population of patients that the new psychiatric hospital will be serving.

LITERATURE REVIEW METHODS

SUMMARY Providing more comprehensive care in

METHODS

CARE MODELS

CARE MODEL ANALYSIS METHODS

CARE MODEL INTRODUCTION An appropriate model for care to be delivered in this setting must be identified. A variety of existing care models were reviewed and analyzed for their resource demands as well as their efficiency in providing access to the appropriate treatment. Selecting a path of care determines the level to which proposed psychiatric programs are integrated into the existing framework. Four different models were studied before establishing which was the most effective: trauma informed, housing first, community based, and integrated medicine.

ABUSE

CARE MODEL ANALYSIS METHODS

TRAUMA INFORMED MODEL

CHILDHOOD TRAUMA DIRECTLY RELATED TO FUTURE MENTAL ILLNESS

FAMILY DYSFUNCTION

UNDERSTANDING PAST TRAUMA CAN INFORM CARE

NEGLECT

With the trauma informed care model, doctors attempt to help patients by understanding the root cause of their illness.11 39

HOUSING FIRST MODEL HOU ENV SING P CAN IRONM ROVID THE BETT ENT S ES A S IR T ER A O PA TAB REA L T D TME HERE IENTS E TO NT

TAL SPI SS O H LNE HE T T TAL IL A NT EN ESE H A M R P WIT TS

IE PAT

PATIENTS WITHOUT HOMES WILL BE GIVEN PROPER HOUSING PRIOR TO STARTING OUTPATIENT TREATMENT

With the housing first model, hospitals provide patients with a place to live before they are treated. This model has been found to reduce the cost and use of health services. 12 40

PATIENTS TREATED AT ZOMBA MAY HAVE TO TRAVEL ACROSS THE COUNTRY BACK TO THEIR HOMES WHEN DISCHARGED

ING NC GO E I R ES S PE EX ISSU LINIC E L LTH L C OP PE HEA OCA L L NTA IER ME TO TH

Local clinics are trained to provide treatment for mental health conditions. They then train traditional healers on how to treat mental health conditions and when to refer them to a hospital.

ONL ARE Y THE 332 SENT MOST SE BED TO S A ZOM VERE RE AVA BA BU PATIE N T ILA BLE ONLY TS

CARE MODEL ANALYSIS METHODS

COMMUNITY BASED MODEL

TS EN E I T PA TH RE T TO TAL E V N SE SE OSPI THE ARE AL H NTR CE

THERE ARE ADDITIONAL COMMUNITY BASED RESOURCES TO HELP SUPPLEMENT THE GAP IN MENTAL HEALTH SERVICES LOCAL CLINICS HAVE RESOURCES AVAILABLE TO HELP PATIENTS WHO PRESENT IN A PRIMARY CLINIC TRADITIONAL HEALERS ARE BETTER TRAINED TO HELP PATIENTS WITH MENTAL ILLNESSES AND REFER THEM TO MENTAL HEALTH CARE PROFESSIONALS

INTEGRATED MEDICAL MODEL The Integrated Medical Model may be beneficial in encouraging people to seek treatment for common mental health conditions. Including mental health professionals in current outpatient wards can ease the internal struggle of a patient to seek mental health treatment. If they mention to a doctor in the outpatient facility that they are feeling depressed, a mental health professional can come to the patientâ&#x20AC;&#x2122;s room and help them address their concerns. This reduces the stigma of patients visiting a mental health clinic as most patients would never actively go to a psychiatrist. The main concern of this care model is that the close proximity of a mental health outpatient clinic to the current outpatient clinic will prevent people from using the hospital because of the immense stigma associated with mental illness in Malawi.14,15,16

CARE MODEL ANALYSIS METHODS

DOCTORS RECOMMEND A MENTAL HEALTH PROFESSIONAL, WHO IS ALREADY A PART OF THE OUTPATIENT CLINIC SERVICE

SEVERE PATIENTS ARE ADMITTED TO THE INPATIENT WARD AT KCH

DOCTORS ARE TRAINED TO RECOGNIZE MENTAL HEALTH ISSUES IN THEIR PATIENTS

THE N I H NTS AT KC E S E INIC PR TS NT CL N IE IE PAT TPAT OU

03 44

METHODS

COMPASSION

SOCIETY COMMUNITY INDIVIDUAL

Compassion is defined as the “sympathetic consciousness of others’ distress together with a desire to alleviate it.” This is stronger than an empathetic sensitivity to the feelings and experiences of another because it requires action to be taken. In the days of what many are referring to as a “compassion crisis,” more professions are being encouraged to redefine what it means to act with compassion and care more about the impression left on someone after an interaction. While this is not isolated to one field, the healthcare sector has specifically struggled to maintain active empathy in patient care. Recent studies in the United States have shown that roughly 70% of opportunities to be compassionate are missed by medical staff and professionals. This is a staggering amount of potentially negative interactions between patients and their caregivers at a very vulnerable point in time for both people involved.17

DEFINING COMPASSION METHODS

COMPASSION CRISIS

A worldwide trend of depersonalization in medicine, often because of a lack of time for doctors to spend with patients, has increased the number of preventable emotional harms.18 The ensuing loneliness results in increased patient stress and additional healthcare costs. The patients feel more like their illness than like an individual.19 The resulting public health problem is magnified in the mental healthcare setting by representing a lack of beliefs in anotherâ&#x20AC;&#x2122;s mental health and dignity. Integrating more compassion in care is not just beneficial for patient adherence and well-being, but also the cost and quality of patient care and retention of healthcare providers.20 A study of 417 patients at Zomba Mental Hospital showed that patients who interacted more with providers for this episode of their illness prior to admission at Zomba typically had a shorter length of stay on the unit. 21Shifting the care model to introduce more compassion may simply start with changing the narrative between patients and staff. The Malawi healthcare system allows for more compassionate care because of the existing communal framework of their culture.

DEFINING COMPASSION METHODS

LACK OF COMPASSION

Worldwide, mental illnesses are not discussed quite as often as illnesses and diseases that have directly physical symptoms. This creates another roadblock to the introduction of compassion in psychiatric care is the intense stigmatization of the field. Mental health is then largely misunderstood due to limited communication about its occurrence rates and normality in society. Compassion plays a large role in activating that communication on a variety of scales as well. Educating the public in both small groups and societal settings will introduce methods for combating mental illness followed by a gentle reintegration into society. In the case of Malawi, compassion also encourages an understanding between medical professions, traditional healers, and cultural leaders that can lead to a more holistic and culturally appropriate method of addressing and destigmatizing mental illness and its patients.

DEFINING COMPASSION METHODS

MENTAL ILLNESS STIGMAS

DEFINING COMPASSION METHODS

COMPASSION IN ARCHITECTURE A set of mechanisms for actions must be introduced into healthcare, and in the case of this project mental health care, to increase resilience on a variety of scales. It becomes the responsibility of built environment designers to align compassion in their work with that of the medical professionals and patients they are creating spaces for.22 This compassion conversation in healthcare has made its way to design professionals in such an impactful way that they are beginning their own conversation about how design “has an ability to respond to and encourage certain behaviors.”23 The need has become clear to have a strong “capacity for mindfulness and compassion” while truly listening to the needs of the users. Developing indoor and outdoor spaces that encourage positive human connection will inspire those users to also act in a kinder and more humane manner if they see someone in distress. The refreshingly dynamic human relationships being built should then be reflected in a dynamic built space that users can have an active relationship with dealing the healing and restorative processes.

It has been proven that it only takes 30 to 60 seconds to be compassionate towards another human being during a time of need.24 A physician taking the time to walk down a hallway with their patient to explain the outlook of their condition in a respectful and comforting manner can make all the difference in both the patientâ&#x20AC;&#x2122;s outcome and physicianâ&#x20AC;&#x2122;s desire to deliver genuine care. There is a growing social purpose in design and it is crucial to consider the ways in which the design of a built environment can improve the lives of mentally ill patients in short- and long-term care facilities. Compassion matters, and when it comes to improving patient lives, compassionate design integrated with compassionate systems of treatment is a must.25,26

DEFINING COMPASSION METHODS

30 TO 60 SECOND RULE

METHODS

DESIGN RESEARCH

DESIGN RESEARCH METHODS

Documents published by the World Health Organization, The South African Development Community, and Malawiâ&#x20AC;&#x2122;s Ministry of Health were evaluated to determine standard methods of care for psychiatric patients in both inpatient and outpatient settings. As these documents recommended the implementation various care models, not one described the programmatic or spatial requirements of the models they described. Throughout this project, standards are identified and developed for these requirements. Through further research and discussions with psychiatrists who have practiced in Malawi and the United States, we have been able to compile a list of programmatic needs, special requirements, and design interventions that are essential for the proper care of psychiatric patients in Malawi.

PROGRAM LIST

OUTPATIENT BLOCK Reception 4 Consulting Rooms 2 Counseling rooms (psychosocial counseling) Toilets (2 for patients, 2 for staff) 2 bathrooms for males and females 4 beds for short stay Data Storage Room 2 Counseling rooms (HTC Counseling and testing at OPD) 2 store rooms at OPD Dispensary Min dining hall for staff / tearoom / restroom Small room as kitchen for preparing tea Addiction program centre 5 offices - 3 for clincians and 2 for nurses

ADMIN BLOCK 1 Psychiatrist Office Min conference room for meetings Computer room / data room 4 toilets for males and 2 for femalesâ&#x20AC;&#x2122; staff Matronâ&#x20AC;&#x2122;s office 1 senior clincian office 1 senior nurse office

MIN M2 25 48 24 144 4 64 16 24 16 25 12 225

MIN M2 12 20 324 9 12 12

Acute section - 24 for females which will include 4 maternal beds Acute section - 20 for males) Rehabilitation section 10 beds for females Rehabilitation section 10 beds for male Infirmary Section 8 beds for female) Infirmary Section 8 beds for male Children and adolescent section 8 beds for girls Children and adolescent section 8beds for boys Geriatric section 8 beds for female) Geriatric section (8 beds for male Kitchen - a separate one for preparing in between meals 2 consultation rooms in all wards Patientsâ&#x20AC;&#x2122; store in all wards 2 staff toilets for each ward 2 changing rooms for each ward 4 patient toilets, 4 patient bathrooms for each ward 2 side wards for staff (2 bedded rooms for male and remale) 2 counseling rooms (psychosocial counseling) Ground for Recreation/rehabilitation 1 dining / cafeteria for patients for each ward 3 seclusion/ single rooms for each acute ward (male and female) Recreation room for activities like prayer, dance, etc ECT room with 4 recovery beds 1 Visitorâ&#x20AC;&#x2122;s lounge for each room Meeting rooms / conference rooms in each ward Nurses station for each ward Offices for ward / unit incharges in each ward Occupational therapy block - kitchen, needle work, weaving, store room, toilets for patients and 2 for staff, small kitchen for cooking demonstration, 2 offices

MIN M2 216 192 96 96 96 96 96 96 96 96 48 12 4 4 4 64 12 800 9 300 100 25 20 64 -

PROGRAM ANALYSIS METHODS

INPATIENT BLOCK

ADJACENCY MATRIX

Each programmatic requirement was HOSPITAL evaluated to determine critical adjacencies, PSYCHIATRIC HOSPITAL secondary adjacencies, and no relationship. OUTPATIENT

MATRIX

ADDICTION CENTER DISPENSARY OCCUPATIONAL THERAPY

OUTPATIENT MATRIX OUTPATIENT

COUNSELING ROOMS STAFF DINING HALL KITCHEN KITCHEN

STAFF DINING HALL

COUNSELING ROOMS

SHORT-STAY BEDS

DATA STORAGE ROOMS

CONSULTATION ROOMS

RECEPTION

OFFICES

OCCUPATIONAL THERAPY

DATA STORAGE ROOMS

DISPENSARY

SHORT-STAY BEDS

ADDICTION CENTER

CONSULTATION ROOMS

OUTPATIENT

INPATIENT

EDUCATION

NURSES STATION

MEETING ROOMS

VISITOR’S LOUNGE

SECULSION ROOMS

COUNSELING ROOMS

CONSULTATION ROOMS

KITCHEN

CAFETERIA

REC ROOM

DAY ROOM

ECT ROOM

INFIRMARY

CHILD WARD

GERIATRIC WARD

REHABILITATION WARD

ACUTE WARD

REHABILITATION WARD GERIATRIC WARD CHILD WARD INFIRMARY

ECT ROOM

DAY ROOM

PROGRAM ANALYSIS METHODS

INPATIENT MATRIX INPATIENT

REC ROOM

CAFETERIA

KITCHEN

CONSULTATION ROOMS

COUNSELING ROOMS

SECULSION ROOMS

VISITOR’S LOUNGE

MEETING ROOMS

NURSES STATION

OFFICE

CRITICAL ADJACENCIES The matrix translated spatially to determine overall adjacencies throughout the site.

ADDICTION CENTER

DISPENSARY

OCCUPATIONAL THERAPY / EDUCATION

OUTPATIENT

INPATIENT ACUTE WARD REHABILITATION WARD GERIATRIC WARD CHILD WARD INFIRMARY ECT ROOM DAY ROOM REC ROOM CAFETERIA KITCHEN

PROGRAM ANALYSIS METHODS

OUTPATIENT ORGANIZATION GREENSPACE

SHORT-TERM STAY BEDS

GREENSPACE

STAFF CAFETERIA

COUNSELING ROOMS

RECEPTION

CONSULTING ROOMS

OFFICES

STAFF KITCHEN

DATA STORAGE

Outpatient organization highlighted a need for separate doctors and patients spaces as well as green spaces that are used by both.

INPATIENT ORGANIZATION PRIVATE GREENSPACE

The inpatient wards need to be connected to all program elements that assist in patient care. The most important adjacencies are to the group therapy, counseling, and consultation rooms.

STAFF BEDS

STAFF LOUNGE OFFICES

GROUP THERAPY ROOMS

WARD

COUNSELING ROOMS

CONSULTATION ROOMS

MEETING ROOM

ECT ROOM

GREENSPACE VISITORâ&#x20AC;&#x2122;S LOUNGE

PROGRAM ANALYSIS METHODS

WARD ORGANIZATION Within each ward, the areas where patients sleep should be close to the day and rec rooms, because this is where patients spend most of their time. These spaces should also have a clear connection to the outdoors.

GREENSPACE

REC ROOM CAFETERIA

BEDS SECULSION ROOM

DAY ROOM

KITCHEN

NURSEâ&#x20AC;&#x2122;S STATION

05 68

METHODS

SPATIAL NEEDS

DEFINING SPACES METHODS Establishing organization at the program and ward levels encourages the development of spatial requirements within those areas. The requirements are broken down into the following four categories: patient safety, patient comfort, community space, and outdoor space. These studies are flexible in their organization and appearance but essential in their included elements. This most basic prototypical information shall be used as a framework for understanding how to apply these concepts across a variety of designed and scaled spaces.

The most important elements in the design of Psychiatric hospitals are those that mitigate the risk of harm for both patients and staff.28 This idea was mentioned by every psychiatrist that was interviewed and should be a central theme for every element within the hospital. The primary method to ensure patient and staff safety is to make every space visible from a central nurseâ&#x20AC;&#x2122;s station. From this location, nurses should be able to monitor all patient activity within the ward.29

DEFINING SPACES METHODS

PATIENT SAFETY

SHELVING TO ORGANIZE MEDICAL RECORDS

SEATING WITH VIEWS DOWN ALL CORRIDORS

NURSES STATION U-SHAPED TO KEEP PATIENTS FROM APPROACHING BACK

NURSES STATION

VIE

RID

C WN

These spaces should be adjacent to all patient areas. Nurses should be able to see all patient activity from this location. S

EW VI

N C R

O R

O ID R

O S

VIE

RID

W DO

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

DOCTOR SITTING CLOSEST TO DOOR

SEATING FOR PATIENT AND FAMILY MEMBER

CONSULT ROOM Consult rooms are where most doctor patient interactions should take place.

STORAGE

WINDOWS PROVIDING NATURAL LIGHT

3.5

DEFINING SPACES METHODS

PRIVATE FROM PATIENTS AND VISITORS

SHELVING TO ORGANIZE MEDICAL RECORDS

STORAGE ROOM Reserved for patients who pose a threat to other patients, staff, or themselves. This room is isolated from all other people in the hospital 3.5

3.5

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

ALL FURNITURE IS IMMOVABLE

ONE PERSON PER ROOM

SECLUSION ROOM Most medical records are kept in print form, a proper storage space is necessary to keep patient documents organized.

WINDOWS PROVIDING NATURAL LIGHT

NOTHING IN ROOM THAT CAN CAUSE PATIENTS HARM

3m 2m

Patient comfort can also be achieved by limiting the number of beds that share the same space.30 It is common for hospitals in Malawi to have an open ward typology, where 30 or more beds are located in a large open room. Psychiatric hospitals should not follow this model. The most common reason for admittance to a Psychiatric hospital in Malawi is schizophrenia, and above all, these patients desire privacy and confidentiality during their treatment.31 It is therefore recommended that patients be kept in rooms with no more than 4 beds. This will allow patients to have greater control over the environments they are in, giving them the freedom to move into areas where they are most comfortable.32

DEFINING SPACES METHODS

PATIENT COMFORT

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

THREE PEOPLE ALL FURNITURE IS PER ROOM, LINEAR IMMOVABLE ORGANIZATION TO MAXIMIZE VIEWS FOR STAFF AT DOOR

PATIENT ROOM_1 A linear organization for a 3 person room can help maintain patient privacy WINDOWS PROVIDING NATURAL LIGHT

CUBBIES PROVIDE PRIVACY AND STORAGE WITHOUT OBSTRUCTING VIEWS FOR STAFF

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

THREE PEOPLE PER ROOM, ORGANIZATION PROVIDES MORE PRIVACY FOR PATIENTS

ALL BEDS ARE IMMOVABLE

PATIENT ROOM_2 Movable partitions allow patients to control their privacy, but over time they may become damaged by normal wear.

WINDOWS PROVIDING NATURAL LIGHT PARTITIONS PROVIDE MORE PRIVACY FOR PATIENTS AND FLEXIBILITY FOR STAFF, CAN BE REMOVED IF NEEDED, MAY BE A SAFETY HAZARD AND CAN BE DAMAGED MORE EASILY

ALL FURNITURE IS IMMOVABLE

FOUR PEOPLE PER ROOM, ORGANIZATION ALLOWS FOR NO VISUAL OBSTRUCTIONS FOR STAFF

PATIENT ROOM_3 Four person rooms can create more efficient hospital layouts, but at the cost of patient privacy

DEFINING SPACES METHODS

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

WINDOWS PROVIDING NATURAL LIGHT NO CUBBIES OR PARTITIONS IN ORDER TO PROTECT THE PATIENTS, MAY BE MORE APPROPRIATE IN AN ACUTE WARD

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

ALL FURNITURE IS IMMOVABLE

THREE PEOPLE PER ROOM, ORGANIZATION PROVIDES MORE PRIVACY FOR PATIENTS

PATIENT ROOM_4 Spiral organizations create more space for patients inside their rooms. WINDOWS PROVIDING NATURAL LIGHT CUBBIES PROVIDE PRIVACY AND STORAGE WITHOUT OBSTRUCTING VIEWS FOR STAFF

From mulitple conversations with mental health professionals, the need for community spaces in the wards was identified. Although, the acute ward has less of a need compared to the long-term ward, including rooms that encourage socialization can be helpful for patients to feel less alone in their struggles. Also having spaces for communal eating, games, puzzles, TV, and radio are beneficial to the patient. Keeping all communal spaces located in front of the nurses station ensures a safer environment for patients and staff.

DEFINING SPACES METHODS

COMMUNITY SPACE

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

MOVEABLE CHAIRS FOR GROUP THERAPY

ROOM CAN BE INCORPORATED INTO OTHER PROGRAM SPACE, DOES NOT NEED TO BE ITS OWN SPACE

GROUP COUNSELING Counseling room with flexible seating to accommodate groups of different sizes. Access to green space.

A S E

A SP

R O O

Space for recreation should be available inside and outside

U O

RECREATION ROOM

TABLES FOR GROUP GATHERING AND GAMES

ROOM CAN BE INCORPORATED INTO OTHER PROGRAM SPACE, DOES NOT NEED TO BE ITS OWN SPACE

DAY ROOM Gathering room for patient socialization when they are not being seen by doctors.

DEFINING SPACES METHODS

WINDOWS IN DOORS FOR THE SAFETY OF DOCTORS AND PATIENTS

A C C ES S TO O U TD O O R A SP C E

PRIVACY FROM PATIENTS

SEATING FOR DOCTORS AND NURSES

FOOD STORAGE

STAFF ROOM

S ES

Staff room for respite from the demands of the job. Private from the patients with access to a private green space.

TO O R E

A SP

OUTDOOR SPACE

Outdoor space is proven to positively influence a patients mental health as well as the staffâ&#x20AC;&#x2122;s satisfaction. When designing an outdoor space, it is important to mitigate harsh noise and unwanted demands which can be done through healing plants. In order to give the patient a feeling of control, minimizing physical restraints in the outdoor space is important. One study noted that patients would return to the psychiatric unit to walk through the garden because of their positive association with their therapeutic benefits. NG TI I A W A E C VI AR I C

I AT P T

REHABILITATION The long-term inpatient ward focuses on occupational therapy and healing by living and working in comfortable space. The terrain can be a bit more challenging with both recreational and work areas.

Acute patients typically desire solitude and isolation from large groups. Occasional partitions allow staff to watch the patients while they explore smaller-scale spaces that are quiet with open sight lines.

ST E R F AS F A E ST AR NT

I AT P N

Patients that have to wait to be admitted to the outpatient ward should be provided with a community-oriented space that is both peaceful and interactive.

COMFORT

T EN

CIVIC SPACE

RESPITE Staff also need their own outdoor space to retreat to away from patients and visitors. Located between wards, staff can choose whether to decompress in groups at tables or alone wandering through rich plantings.

ACUTE INPATIENT

OUTPATIENT

INPATIENT

OUTPATIENT DEFINING SPACES METHODS

LONG-TERM INPATIENT

HOSPITAL DESIGN

The following section details the design process from site selection to visualizing patient experience. This process was supported by the research conducted previously in this book. While a variety of designs were considered throughout the progression, only the most recent plans are shown here to highlight the resulting culmination of research becoming intervention.

06 88

SITE SELECTION

SITE PLANNING HOSPITAL DESIGN

It was established that site specificity would best represent how to apply standard program and spatial requirements in a realistic setting. Prior to this work, a 20-year framework plan for growth and development was designed for Kamuzu Central Hospital (KCH) in Malawiâ&#x20AC;&#x2122;s capital city of Lilongwe. Portions of that plan were dedicated to future development where programs like a psychiatric hospital could one day be built. Given the need for this program in both Lilongwe and the hospital complex itself, KCH was elected as the most suitable site for a case study. The specific location of the psychiatric facilities on site was decided after analyzing a multitude of centralized and decentralized program schemes.

CENTRALIZED

Locating the psychiatric hospital with all outpatient and inpatient wards and clinics in one central location helps consolidate resources.

OUTPATIENT

INPATIENT ACUTE

INPATIENT LONG-TERM

PRIVATE ENTRANCE FUTURE DEVELOPMENT

LINGADZI NAMILOMBA FOREST RESERVE

NATIVE MEADOW ADOW FFOR SLOPE STABILIZATION C CANCER ENTER CENTER CANCER CENTER

CANCER R CENTER

FACILITIES

NATIVE TREE GROVES

LI OR INST LONG TH IT W NEU OPA UTE E RO EDIC OF SUR S A GER ND Y

CANCER CENTER

PAR

CLOSE PROXIMITY TO NEUROSURGERY DEPARTMENT CLOSE PROXIMITY TO FARMING, TO BE USED IN OCCUPATIONAL THERAPY

PAR KIN G

IEN

TIEN

TIE

INPA

KIN

INPA

PA T

PARKING

FUTURE

CENT RA INPA LIZEDDEVELOPMENT OU TIEN T (ACU TPATIE NT TE + LONG + -TER M)

SITE PLANNING HOSPITAL DESIGN

CENTRALIZED_01

TIEN

MATERNITY

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

PARKING

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

EA TM PL EN AN T NI CE NG NT CE ER NT & ER

INPATIENT

PHARMACY & LAB

ADMIN

PEDIATRICS

DIA

ICS

EDUCATION CHAPEL

BAYLOR

KITCHEN

DIA TR IC S

MORGUE

PARKING

PEDIATRICS

MATERNITY

PARKING

FARMING

FAR FROM ER, OUTPATIENT, AND EXISTING ENTRANCES

NATIVE TREE GROVE

FARMING

FUTURE DEVELOPMENT

FARMING

RIPARIAN BUFFER

BIOFILTRATION WITH UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

Locating the psychiatric hospital adjacent to the new neuro ward can increase the communication between mental health professionals and neurologists regarding the treatment of epilepsy. Over 2/3 of children admitted to a psychiatric hospital in sub-Saharan Africa are admitted for epilepsy despite neurologists typically providing treatment.33

CENTRALIZED_02 CE IN NTR PA A TIE LIZ NT ED (A OU CU TP TE AT + L IEN ON T + GTE RM )

PRIVATE ENTRANCE FUTURE DEVELOPMENT

LINGADZI NAMILOMBA FOREST RESERVE

NATIVE VE M MEADOW FOR SLOPE STABILIZATION ATTIO CANCER CENTER CANCER CENTER

NATIVE TREE GROVES

CONNECTION TO EXISTING HOSPITAL

CANCER CENTER

FACILITIES

LI OR INST LONG TH IT W NEU OPA UTE E RO EDIC OF SUR S A GER ND Y

CANCER CENTER

PAR

FUTURE DEVELOPMENT

PAR KIN G

IEN

TIEN

TIE

INPA

KIN

INPA

PA T

PARKING

TIEN

MATERNITY

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

PARKING

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

EA TM PL EN AN T NI CE NG NT CE ER NT & ER

INPATIENT

PHARMACY & LAB

ADMIN

PEDIATRICS

DIA

ICS

EDUCATION CHAPEL

BAYLOR

KITCHEN

DIA TR IC S

MORGUE

PARKING

PEDIATRICS

MATERNITY

PARKING

FARMING

CLOSE PROXIMITY TO ER AND OUTPATIENT

NATIVE TREE GROVE

FARMING

FUTURE DEVELOPMENT

FARMING

RIPARIAN BUFFER

BIOFILTRATION WITH UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

By placing the psychiatric hospital in the North corner of the site provides a discrete entrance into the hospital for patients while also being located close to the necessary hospital programs such as outpatient and emergency room.34

SITE PLANNING HOSPITAL DESIGN

CENTRALIZED_03 FAR FROM ER, FUTURE OUTPATIENT, ANDDEVELOPMENT EXISTING ENTRANCES

LINGADZI NAMILOMBA FOREST RESERVE

NATIVE MEADOW FOR SLOPE STABILIZATION CANCER CENTER CANCER CENTER

CANCER CENTER

FACILITIES

NATIVE TREE GROVES

LI OR INST LONG TH IT W NEU OPA UTE E RO EDIC OF SUR S A GER ND Y

CANCER CENTER

PAR

PAR KIN G

FUTURE DEVELOPMENT

IEN

TIEN

TIE

INPA

KIN

INPA

PA T

PARKING

TIEN

MATERNITY

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

PARKING

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

EA TM PL EN AN T NI CE NG NT CE ER NT & ER

INPATIENT

PHARMACY & LAB

ADMIN

PEDIATRICS

DIA

ICS

EDUCATION CHAPEL

BAYLOR

KITCHEN

DIA TR IC S

MORGUE

PARKING

PEDIATRICS

MATERNITY

PARKING

FARMING

CLOSE PROXIMITY TO NURSING COLLEGE

NATIVE TREE GROVE

FARMING

CLOSE PROXIMITY TO FARMING, TO BE USED IN OCCUPATIONAL FARMING THERAPY RIPARIAN

FUTURE ENT DEVELOPMENT CENTRALIZED OUTPATIENT + INPATIENT (ACUTE + LONG-TERM)

BUFFER

PRIVATE ENTRANCE BIOFILTRATION WITH

UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

Locating the psychiatric hospital south of the nursing hospital provides a direct connection to the nursing students who one day might be the primary mental health professionals at the psychiatric hospital as psychiatric nurses are more prevalent that psychiatrists. The location does not provide close proximity to the ER and outpatient wards.

DECENTRALIZED

Locating the psychiatric hospital across the campus provides an optimal environment for each ward.

OUTPATIENT

INPATIENT ACUTE

INPATIENT LONG-TERM

MAY BE TOO CLOSE FUTURE TO DEVELOPMENT THE MAIN NATIVE MEADOW FOR SLOPE STABILIZATION INTERSECTION OF THE HOSPITAL

FAR FROM ER, OTHER HOSPITAL PROGRAMS IN CASE OF EMERGENCY

LINGADZI NAMILOMBA FOREST RESERVE CANCER CENTER CANCER CENTER

CANCER CENTER

FACILITIES

NATIVE TREE GROVES

LI OR INST LONG TH IT W NEU OPA UTE E RO EDIC OF SUR S A GER ND Y

CANCER CENTER

PAR

CLOSE PROXIMITY TO FARMING, TO BE USED IN OCCUPATIONAL THERAPY

PAR KIN G

LONG -TER INPA FUTURE M TIEN PSDEVELOPMENT YCHI T ATRY WAR D

IEN

TIEN

TIE

INPA

KIN

INPA

PA T

PARKING

SITE PLANNING HOSPITAL DESIGN

DECENTRALIZED_01

TIEN

MATERNITY

PARKING

EA TM PL EN AN T NI CE NG NT CE ER NT & ER

ADMIN

DIA

ICS

EDUCATION BAYLOR

KITCHEN

DIA TR IC S

CHAPEL

PEDIATRICS

PARKING

OUTPATIENT PSYCHIATRY WARD

PARKING

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

MORGUE

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

MATERNITY

ACUTE INPATIENT PSYCHIATRY WARD

INPATIENT

PHARMACY & LAB

PEDIATRICS

MATERNITY

PARKING

FARMING

TOO CENTRALLY LOCATED? NEED A MORE DISCRETE ENTRANCE?

NATIVE TREE GROVE

FARMING

FUTURE DEVELOPMENT

FARMING

RIPARIAN BUFFER

BIOFILTRATION WITH UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

The acute ward and outpatient clinic are located directly adjacent to the ER and current outpatient clinics to optimize programmatic connections for the patients. Connecting the outpatient clinics encourages an Integrated Medical Model approach to care. The long-term care inpatient ward is located in the northeast of the site to provide a calm place away from the congestion of the hospital.

DECENTRALIZED_02 AC PS UTE WA YCH INP RD IAT AT RY IEN T

PRIVATE ENTRANCE

FUTUR FUTURE DEVELOPMENT DEVELOPMEN

CONNECTION TO EXISTING HOSPITAL

OU PS TPA WA YCH TIEN RD IAT T RY

NATIVE VE M MEADOW FOR SLOPE LOPE STABILIZATION ATIO CANCER CENTER CANCER CENTER

CANCER CENTER

FACILITIES

NATIVE TREE GROVES

LI OR INNSTTILOONG TH ITT W NEU OPA UTE E RO EDIC OF SUR S A GER ND Y

CANCER CENTER

FAR FROM ER, OTHER HOSPITAL PROGRAMS IN CASE OF EMERGENCY

LINGADZI NAMILOMBA FOREST RESERVE

PAR

CLOSE PROXIMITY TO FARMING, TO BE USED IN OCCUPATIONAL THERAPY

PAR KIN G

LONG -TER INPA FUTURE M TIEN PSDEVELOPMENT YCHI T ATRY WAR D

IEN

TIEN

TIE

INPA

KIN

INPA

PA T

PARKING

TIEN

MATERNITY

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

PARKING

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

EA TM PL EN AN T NI CE NG NT CE ER NT & ER

INPATIENT

PHARMACY & LAB

ADMIN

PEDIATRICS

DIA

ICS

EDUCATION CHAPEL

BAYLOR

KITCHEN

DIA TR IC S

MORGUE

PARKING

PEDIATRICS

MATERNITY

PARKING

FARMING

CLOSE PROXIMITY TO ER AND OUTPATIENT

NATIVE TREE GROVE

FARMING

FUTURE DEVELOPMENT

FARMING

RIPARIAN BUFFER

BIOFILTRATION WITH UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

Placing the outpatient clinic and acute inpatient ward in the North corner of the site provides a discrete entrance into the hospital while also allowed efficient access to necessary hospital programs suchs as the outpatient and emergency areas. The long-term care inpatient ward is located in the Northeast of the site to provide a calm place away from the congestion of the hospital.

FUTURE DEVELOPMENT

FAR FROM ER, OTHER HOSPITAL PROGRAMS IN CASE OF EMERGENCY

LINGADZI NAMILOMBA FOREST RESERVE

NATIVE MEADOW FOR R SLOP SSLOPE STABILIZATION R CANCER CENTER CANCER CENTER

CANCER CENTER

FACILITIES

NATIVE TREE GROVES

LI OR INST LONG TH T IT WE T NEU OPA UTE E I E OF RO ED CSS SUR IC GER AND Y

CANCER CENTER

PAR

CLOSE PROXIMITY TO FARMING, TO BE USED IN OCCUPATIONAL THERAPY

TIE

TIEN

LONG -TER INPAFUTURE M TIEN PS DEVELOPMENT YCHI T ATRY WAR D

PAR KIN G

INPA

KIN

INPA

PA TIE

PARKING

SITE PLANNING HOSPITAL DESIGN

DECENTRALIZED_03

TIEN

MATERNITY

T T CE NG NT CE ER NT & ER

INPATIENT

EA TM PL EN AN NI

BIOFILTRATION WITH UNDERGROUND STORAGE

HI FA V TR MI LY

SURGERY

PARKING

MATERNITY

POST- OP INPATIENT

MATERNITY

TRANSITIONAL

MATERNITY

PHARMACY & LAB

ADMIN

PEDIATRICS

DIA

ICS

EDUCATION CHAPEL

BAYLOR

KITCHEN

DIA TR IC S

MORGUE

PARKING

PEDIATRICS

MATERNITY

PARKING

FARMING

CLOSE PROXIMITY TO ER AND OUTPATIENT

NATIVE TREE GROVE

ENT

ATI

INP

ENT ATI Y OUTP CHIATR PSY D R WA

FARMING

Y TE FUTURE ACU CHIATR PSY D DEVELOPMENT AR W

FARMING

PRIVATE ENTRANCE

RIPARIAN BUFFER

BIOFILTRATION WITH UNDERGROUND STORAGE

FARMING

FARMING CO-OP WITH INFORMAL SETTLEMENT

Locating the outpatient clinic and acute ward south of the nursing hospital provides a direct connection to the nursing students who one day might be the primary mental health professionals. The long-term care inpatient ward is located in the northeast of the site to provide a calm place away from the congestion of the hospital.

100

FINAL SITE LOCATION101

07 102

WARD DESIGN

103

GUIDING PRINCIPALS 104

INDEPENDENCE

DESIGN SPACES THAT ARE LEGIBLE AND NAVIGABLE IN ORDER INCREASE DESIGN SPACES THATTO ARE LEGIBLEPATIENT AND NAVIGABL PATIENT CONFIDENCE WHILE IN LIVING IN A HIGHLY-D CONFIDENCE WHILE LIVING A HIGHLYDEPENDENT MEDICAL SETTING.

CONSCIOUSNESS

ASSIST PATIENTS IN BECOMING AWARE AND CONSCIOUS OF THEIRINSURROUNDINGS THROUGH ASSIST PATIENTS BECOMING AWARE AND CONS SURROUNDINGS THROUGH SENSORY STIMULATION SENSORY STIMULATION AND THE PASSAGE OF TIME.

CONNECTEDNESS

COUNTERACT FEELINGS OF ISOLATION IN SPACES COUNTERACT FEELINGS ISOLATION IN SPACES T THAT ENCOURAGE SOCIALOF INTERACTION AND INTERACTION CONTACT NATURE CONTACT WITHAND NATURE WHENWITH PATIENTS AREWHEN P READY TO DO SO.

PURPOSE

PHSYICAL ACTIVITY

REST

ENCOURAGE PATIENTS TO ESTABLISH A ROLE ENCOURAGE PATIENTS TO ESTABLISH A ROLE IN SO IN SOCIETY THROUGH WORK OPPORTUNITIES OPPORTUNITIES AND RESPONSIBILITIES WITHIN TH AND RESPONSIBILITIES WITHIN THE HOSPITAL CAMPUS.

PROVIDE OPPORTUNITIES FOR MOVEMENT PROVIDE OPPORTUNITIES FOR MOVEMENT AND AC AND ACTIVITY AT VARIETY OF INTENSITIES TOEXPERI INTENSITIES TOAACCOMODATE MULTI-USER ACCOMMODATE MULTI-USER EXPERIENCES AND CHALLENGES.

ACCOMMODATE SAFE AND COMFORTABLE REST ACCOMMODATE SAFE AND COMFORTABLE REST AR AREAS TO INCREASE PATIENT WELLBEING, TIME WELLBEING, TIME FOR REFLECTION, AND OVERALL FOR REFLECTION, AND OVERALL PRIVACY.

Van der Walt, R., & Breed, I. (2012 psychiatric hospital. South

105

INPATIENT WARD MODULE 106

DEFINING WARDS HOSPITAL DESIGN

ALL INPATIENT WARDS HAVE A CENTRAL SPINE THAT HOLDS PROGRAM ESSENTIAL TO MENTAL HEALTH PROFESSIONALS. PATIENT ROOMS ARE LOCATED ON BOTH SIDES OF THIS SPINE, ALLOWING DOCTORS TO EASILY SERVE ALL PATIENTS.

PATIENTS

PAT IE

NTS

NTA

EAL TH P

ROF

PATIENTS

ESS

NTS

ION A

PAT IE

PATIENTS

107

CLINICAL OFFICER CORE ALL INPATIENT WARDS ARE DESIGNED TO HOLD PROGRAM ELEMENTS THAT ARE ESSENTIAL TO MEDICAL PROFESSIONALS AT THEIR CORE. THIS ALLOWS THOSE PIECES OF PROGRAM TO SERVE BOTH SIDES OF THE WARD, EASING THE STRAIN ON THE HOSPITALâ&#x20AC;&#x2122;S LIMITED RESOURCES AND ALLOWS NURSES AND CLINICAL OFFICERS TO MORE EFFECTIVELY MONITOR THE PATIENTS

CONSULT ROOMS NURSES STATION

BATHROOMS NURSES STATION CONSULT ROOMS 108

THE MOST IMPORTANT ELEMENT OF THE INPATIENT WARDS IS THE NURSEâ&#x20AC;&#x2122;S STATION. PATIENTS MUST BE VISIBLE FROM THIS LOCATION AT ALL TIMES TO ENSURE THEIR SAFETY IN THE WARD. TO KEEP AN IDEAL PATIENT TO STAFF RATIO OF 1:10 THE WARD WILL NEED TO BE STAFFED BY 8 MEDICAL PROFESSIONALS.

DEFINING WARDS HOSPITAL DESIGN

NURSES STATION

109

PATIENT ROOMS PATIENT ROOMS ARE KEPT AT THE EDGES OF THE WARDS. THEIR ANGLES ALLOW NURSES TO LOOK DIRECTLY INTO THE ROOMS FROM THE NURSES STATION. 3 PERSON ROOMS ALLOW PATIENTS TO CONTROL HOW MANY PEOPLE THEY INTERACT WITH AT ONE TIME.

3 PATIENTS

9 PATIENTS 36 PATIENTS ONE WARD

110

ALL INPATIENT WARDS HOUSE ENCLOSED COURTYARDS WHERE A MAJORITY OF PATIENT ACTIVITY WILL TAKE PLACE. THE UNCOVERED COURTYARDS ARE SUPPLEMENTED BY COVERED GROUP THERAPY SPACES AND DAY SPACES THAT CAN BE USED WHEN IT IS RAINING. PATIENTS WILL EAT THEIR MEALS IN THESE SPACES DURING THE DAY.

DEFINING WARDS HOSPITAL DESIGN

COURTYARDS

GROUP THERAPY DAY SPACE

GATHERING SPACE

111

USER GROUPS

ACUTE

GERIATRIC

REHAB

0-28 DAYS

>28 DAYS

DEPRESSION ANXIETY BIPOLAR DISORDER

DEMENTIA ALZHEIMERâ&#x20AC;&#x2122;S

SCHIZOPHRENIA PTSD

LOW

MODERATE

HIGH

18-45

45+

18-45

HIGH

LOW

LENGTH OF STAY

ILLNESSES

STIMULATION

AGE

112

STRUCTURE

PATIENT ANALYSIS HOSPITAL DESIGN

LEVELS OF CARE ON THIS CAMPUS ARE DETERMINED BY A VARIETY OF FACTORS. UNDERSTANDING THESE FACTORS ALLOWS US TO MODIFY OUR INPATIENT WARD MODULE TO BETTER SUIT THEIR USERS

ADOLESCENT OUTPATIENT PEDIATRICS

INFIRMARY ADDICTION

>28 DAYS

1 WEEK

1 DAY

AUTISM EPILEPSY DEPRESSION

AUTISM EPILEPSY

ALCOHOLISM DRUG USE

CO-MORBID MENTAL PHYSICAL

DEPRESSION ANXIETY

LOW

MODERATE

HIGH

18+

ALL

HIGH

MODERATE

LOW

MODERATE

10-18

5-10

MODERATE

113

REHAB AND GERIATRIC LENGTH OF STAY

STIMULATION

THESE PATIENTS WILL REQUIRE SPACES THAT VARY IN SIZE AND FUNCTION TO HELP SUPPORT THEIR LONGER STAY AND TO BREAK THE MONOTONY OF LIVING IN THIS FACILITY

REHAB AND GERIATRIC PATIENTS CAN HANDLE THE MOST EXTERNAL STIMULI OUT OF THE INPATIENT GROUPS. THEIR ACTIVITIES WILL INCLUDE FARMING, GROUP THERAPY, AND OCCUPATIONAL THERAPY

ILLNESSES

THE TREATMENT FOR PATIENTS IN THESES WARDS FOCUSES ON REINTEGRATION INTO SOCIETY. MOST OF THEIR THERAPY WILL BE CONDUCTED IN GROUPS

STRUCTURE

THE PATIENT POPULATIONS IN THESE WARDS HAVE THE MOST FREEDOM OUT OF THE INPATIENT GROUPS. THEY WILL STILL HAVE A DAILY SCHEDULE, AND WILL BE THE GROUP TO MOST FREQUENTLY MOVE IN AND OUT OF THE WARDS

ENTRY

WARD DIV

ISION

114

DEFINING WARDS HOSPITAL DESIGN

THE PASSAGE OF TIME IS EVIDENT FOR REHAB PATIENTS WHERE THEY CAN CHOOSE TO EXPLORE DEMONSTRATION PERMACULTURE GARDENS IN THE DRY SEASON OR FUNCTIONAL RAIN GARDENS IN THE WET SEASON.

GERIATRIC PATIENTS CAN SPEND THEIR TIME OUTSIDE MEANDERING THROUGH PERENNIAL MEADOWS WITH FOUR-SEASON INTEREST OR JOINING AS A GROUP FOR HEALING DISCUSSIONS AND STORYTELLING.

115

PEDIATRIC AND ADOLESCENT LENGTH OF STAY

CHILDREN THAT ARE ADMITTED TO THIS WARD WILL NEED TO CONTINUE THEIR EDUCATION WHILE THEY ARE BEING TREATED.

STIMULATION

ILLNESSES

PROVIDING SPACE FOR THESE PATIENTS TO PLAY IS AN IMPORTANT ELEMENT OF THEIR THERAPY AND GENERAL HAPPINESS IN THE WARD

PATIENTS IN THESE WARDS ARE LIKELY TO HAVE SEVERE FORMS OF THEIR ILLNESSES. THEY WILL NEED TO BE MONITORED CLOSELY WITH A HIGHER STAFF TO PATIENT RATIO

STRUCTURE

PEDIATRIC AND ADOLESCENT PATIENTS WILL HAVE A HIGHLY STRUCTURED SCHEDULE. THIS IS THE SMALLEST PATIENT POPULATION SO THEY WILL PARTICIPATE IN MANY SMALL GROUP ACTIVITIES

CLASSROOMS 116

DEFINING WARDS HOSPITAL DESIGN A BALANCE BETWEEN PHYSICAL ACTIVITY AND REST IS PRIORITIZED HERE TO ALLOW PEDIATRIC AND ADOLESCENT PATIENTS TO EXPEL ENERGY IN A POSITIVE WAY AND CONTINUE TO GET AN EDUCATION IN A NATURAL SETTING.

117

ACUTE LENGTH OF STAY

STIMULATION

ILLNESSES

STRUCTURE

THE HIGH TURNOVER OF PATIENTS IN THIS WARD MEANS FURNITURE AND OTHER HOSPITAL ELEMENTS WILL WEAR QUICKLY

PATIENTS IN THIS WARD ARE THE MOST SENSITIVE ON THE CAMPUS. THEY REQUIRE A LOT OF TIME ALONE WITH LITTLE EXTERNAL STIMULATION. MOST OF THEIR STAY WILL BE SPENT INSIDE THE WARD

ACUTE PATIENTS CAN POSE THE GREATEST THREAT TO THEMSELVES OR OTHERS. FOR THIS REASON, SECLUSION ROOMS ARE ADDED TO THE WARD WHERE PATIENTS CAN BE KEPT SAFE

THE SIZE AND ILLNESSES FOUND IN THIS WARD REQUIRE A STRUCTURED ENVIRONMENT. PATIENTS WILL NOT FREQUENTLY LEAVE THE WARD DURING THEIR TREATMENT

ECT ROOM ADDICTION PATIENT ENTRY

2 SECLUSION ROOMS 8 FOR WARD

118

DEFINING WARDS HOSPITAL DESIGN SMALL-SCALE SPACES ARE CAREFULLY DEVELOPED IN A WAY THAT DO NOT DISRUPT SIGHTLINES FROM THE NURSEâ&#x20AC;&#x2122;S STATION. PATIENTS CAN CHOOSE TO REFLECT IN AN ISOLATED SETTING OR JOIN SMALL GROUP SPACES WHEN THEY FEEL READY TO.

119

INPATIENT ORGANIZATION

REHAB INPATIENT

GERIATRIC INPATIENT

90’

90’ ACUTE INPATIENT

90’

ADOLESCENT INPATIENT

PEDIATRIC INPATIENT

INPATIENT WARDS ARE CONNECTED VIA CENTRAL COVERED PATHWAYS. EXTENDING OUT FROM EACH WARD IS A 90 FOOT LONG PATH THAT LEADS TO OUTDOOR BREAKOUT SPACES. IN THESE AREAS DOCTORS WILL BE ABLE TO CONNECT WITH THEIR PATIENTS IN AN INTIMATE SETTING.

120

90’ CAMPUS ORGANIZATION HOSPITAL DESIGN

90’

121

INPATIENT ORGANIZATION 122

REHAB INPATIENT

GERIATRIC INPATIENT

CAMPUS ORGANIZATION HOSPITAL DESIGN

STAFF REST AREA

ACUTE INPATIENT INFIRMARY

ADOLESCENT INPATIENT

PEDIATRIC INPATIENT

THE PINWHEEL ORGANIZATION OF THE MAJOR INPATIENT WARDS CREATES A SET OF MINOR AXES TO BE DEVELOPED AND INFILLED WITH THE INFIRMARY AND STAFF REST AREAS.

123

CENTER CIRCULATION

B A

124

CAMPUS ORGANIZATION HOSPITAL DESIGN

PATHWAY SECTIONS LEVEL A CIRCULATION PRIMARY MOVEMENT

COVERED WALKWAY 10 FEET WIDE

HIGH TRAFFIC

AMPLE SEATING

FLEXIBLE BOUNDARIES

FRUIT TREE ALLEE OPEN SPACE BUFFER FOR SEATING

LEVEL B CIRCULATION SECONDARY ACCESS

COVERED WALKWAY 6 FEET WIDE

CANOPY TREE

INACCESSIBLE TO PATIENTS

WARD-SPECIFIC TRAFFIC

DENSE VEGETATION SCREEN

BORDER PLANTERS

125

CENTER CIRCULATION

D C

126

CAMPUS ORGANIZATION HOSPITAL DESIGN

PATHWAY SECTIONS LEVEL C CIRCULATION CHOICE CIRCULATION

UNCOVERED WALKWAY 3 FEET WIDE

SENSORY PLANTINGS

ACCESSIBLE REST AREAS

GENTLE MEANDERING

FLEXIBLE OPEN SPACE

CANOPY TREE

LEVEL D CIRCULATION HEALING PATHS

UNCOVERED WALKWAY 3 FEET WIDE

DENSE VEGETATION SCREEN

PRIVATE WALKWAYS

DENSE VEGETATION SCREEN

INTIMATE SEATING AREAS

127

OUTPATIENT SERVICES 128

CAMPUS ORGANIZATION HOSPITAL DESIGN IN AN OUTPATIENT SETTING, VISITORS AND PATIENTS ARRIVE AT THE ENTRY TO THE COMPLEX WHERE THEY HAVE THEIR FIRST CONSULTATION WITH A MENTAL HEALTH PROFESSIONAL. WHILE THEY WAIT FOR THEIR CONSULT, THEY CAN GATHER IN ONE OF MANY CIVIC SPACES OR ATTEND CLASSES.

129

OUTPATIENT LENGTH OF STAY

STIMULATION

ILLNESSES

STRUCTURE

PATIENTS THAT COME TO THE OUTPATIENT CENTER ONLY STAY FOR THE DAY. LINES FOR THE DISPENSARY OR THE WAIT FOR THEIR COUNSELING SESSION CAN BE LONG

WHILE THEY WAIT, PATIENTS CAN SIT IN THE COVERED WAITING AREA, ATTEND ANY MENTAL HEALTH CLASSES THAT ARE RUNNING, OR PLAY A GAME OF SOCCER ON THE FIELD

PATIENTS VISITING THIS WARD DO NOT LIVE AT THE HOSPITAL. THEIR ILLNESS IS ABLE TO BE MANAGED WITH REGULAR COUNSELING SESSIONS AND MEDICATION

THERE IS LITTLE STRUCTURE TO THE OUTPATIENT WARD. THESE PATIENTS ARE HIGHLY ACCLIMATED TO THEIR ENVIRONMENT AND DO NOT NEED A DAILY SCHEDULE

INPATIENT CHECK IN DISPENSARY ADMITTED PATIENTS

ADDICTION CENTER

ADMITTED PATIENTS

EDUCATION

OFFICES

CONSULT ROOMS

OUTPATIENT CHECK IN PUBLIC

130

SOCCER FIELD

DEFINING WARDS HOSPITAL DESIGN THE DISPENSARY ACTS AS A TRANSITION POINT EITHER INTO THE INPATIENT SETTING, THE ADDICTION CENTER, OR BACK OUT INTO THE COMMUNITY.

131

132

OUTPATIENT PERSPECTIVE133

CAMPUS ORGANIZATION THE MAIN AXIS THAT THE OUTPATIENT MODULE CREATES ALLOWS PATIENTS TO ACCESS ALL NECESSARY PROGRAM IN AN EFFICIENT WAY. THE BALANCE BETWEEN GATHERING AND CIRCULATION IN THIS SETTING ALLOWS SPACE FOR CONVERSATIONS THAT BREAK DOWN STIGMA.

STAFF REST AREA

REHAB INPATIENT

GERIATRIC INPATIENT

ACUTE INPATIENT INFIRMARY INPATIENT CHECK IN DISPENSARY

ADDICTION CENTER

ADOLESCENT INPATIENT EDUCATION

PEDIATRIC INPATIENT

CONSULT ROOMS

OFFICES OUTPATIENT CHECK IN

134

SOCCER FIELD

THIS CAMPUS DEALS WITH MANY HIGHLY SENSITIVE PATIENTS. IN ORDER TO ENSURE THAT THESE PATIENTS AND THE PUBLIC ARE KEPT SAFE MOVEMENT THROUGHOUT THE CAMPUS IS HIGHLY CONTROLLED. SEPARATING THE HIGHLY PUBLIC OUTPATIENT AREA AND THE PRIVATE INPATIENT WARDS IS THE INPATIENT CHECK IN. THIS IS THE ONLY WAY ANYONE CAN MOVE IN OR OUT OF THE CENTER OF CAMPUS.

STAFF REST AREA

ADMITTED PATIENTS ONLY

CAMPUS ORGANIZATION HOSPITAL DESIGN

CAMPUS SECURITY

ADDICTION CENTER

INPATIENT CHECK IN DISPENSARY

RESTRICTED ACCESS

PUBLIC ZONE OUTPATIENT CHECK IN

135

7:30am 7:30am

Patient A presents Patient in theAoutpatient presents clinic in thefor outpatient clinic for an issue not related an issue to mental not related health.to mental health.

7:30am 7:30am 8:30am 8:30am 9:00am 9:00am PATIENT PATIENT B B MAN, 45 MAN, 45 10:00am 10:00am DEPRESSION DEPRESSION 7:30am 7:30am 11:00am 11:00am 8:30am 8:30am 1:00pm 1:00pm 9:00am 9:00am PATIENTPATIENT B B 4:30pm 4:30pm MAN, 45MAN, 45 10:00am 10:00am DEPRESSION DEPRESSION 11:00am 11:00am

Patient B arrives Patient at the psych B arrives outpatient at the psych clinic outpatient clinic early in the morning. early in the morning.

She mentioned toShe hermentioned doctor thattoshe herhad doctor that she had been feeling anxious. been feeling anxious. Her doctor askedHer relevant doctorquestions asked relevant and questions and determines she would determines benefitshe from would the benefit from the outpatient psychiatric outpatient clinic psychiatric clinic

8:30am 8:30am

He waits outside He of reception waits outside in theofwaiting reception in the waiting room. room.

PATIENT DAILY SCHEDULES 9:00am 9:00am PATIENT PATIENT A A WOMAN, WOMAN, 25 25 ANXIETY ANXIETY

7:30am 7:30am 10:00am 10:00am 8:30am 8:30am 2:30pm 2:30pm PATIENTPATIENT A A 9:00am 9:00am WOMAN,WOMAN, 25 25 3:30pm 3:30pm ANXIETYANXIETY 10:00am 10:00am 4:30pm 4:30pm

UTILIZED KCH OUTPATIENT UTILIZED SERVICES KCH OUTPATIENT & SERVICES & PSYCHIATRIC OUTPATIENT PSYCHIATRIC CLINIC OUTPATIENT CLINIC INTEGRATED MEDICAL INTEGRATED MODEL MEDICAL MODEL

He sees a psychiatric He sees officer a psychiatric after only waiting officer after only waiting an hour. an hour.

She goes to the outpatient She goes to psychiatric the outpatient clinic psychiatric clinic and checks in at and the reception checks indesk. at the reception desk. Patient A sits in the Patient waiting A sits area in outside the waiting of area outside of reception. reception.

Patient A presents inPatient the outpatient A presents clinic in the for outpatient clinic for an issue an to issue mental health. related mental Therenot is arelated long wait There to see is not a the long clinical wait toofficers see thehealth. clinical officers so she decides tosoattend she decides a nearby to education attend a nearby education session while shesession waits. while she waits. SheAtmentioned to her She mentioned that she to had her doctorabout that she that session she At doctor that learned session about she the learned causes the had causes been anxious. of feeling mental anxious. illness been of andmental itfeeling helped illness herand break it helped down her break down Herthe doctor asked Her doctor questions asked and relevant questions and stigma sherelevant carried. the stigma she carried. determines she would determines benefit from she the would benefit from the outpatient psychiatric outpatient clinic psychiatric clinic Patient A is seenPatient by a clinical A is seen officer bytrained a clinical officer trained in psychiatry. He inconfirms psychiatry. that He sheconfirms has that she has Sheanxiety goes toand theprescribed outpatient She goes to prescribed the outpatient clinica benzodiazepine. psychiatric clinic anxiety apsychiatric and benzodiazepine. and checks in at theand reception checksdesk. in at the reception desk. Patient A sits in the Patient waiting Aarea sitsoutside in the waiting of area outside of She goes to the reception. dispensary She goes toand thewaits dispensary in a long and waits in a long reception. line. She receivesline. herShe medicine. receives her medicine.

UTILIZED PSYCHIATRIC UTILIZED OUTPATIENT PSYCHIATRIC OUTPATIENT CLINIC CLINIC

4:1 4:1

10 11

UTILIZED EMERGENCY UTILIZED ROOM &EMERGENCY R

He realizes that he has He realizes 5 hours that to wait he has for the 5 hours to wait INPATIENT for the ACUTE PSYCHIATRIC INPATIENT ACUTE WARD PSYCHIA minibus to go homeminibus so he walks to gotohome the market so he walks to the market to get lunch. The market to getislunch. run byThe themarket long- is run by the longterm psychiatric patients. term psychiatric patients. He saw a posted forHe a class saw aonposted managing for a class on managing depression and attends depression it. and attends it.

2:30pm 2:30pm 3:30pm 3:30pm 4:30pm 4:30pm

PATIENTPATIENT C MAN, 32MAN, 3 SUICIDE ATTEMPT SUICIDE ATT

1:00pm 1:00pm

Patient A is seen byPatient a clinical A isofficer seen trained by a clinical officer trained in psychiatry. He confirms in psychiatry. that sheHehas confirms that she has anxiety and prescribed anxiety a benzodiazepine. and prescribed a benzodiazepine.

PATIENT PATIENT C MAN, 32 MAN, 3 SUICIDESUICIDE ATTEMPT ATT

The clinical officerThe determines clinical officer that his determines current that his current anti-depression isanti-depression not working and is prescribes not working and prescribes him a different one. him a different one. Patient B arrives at Patient the psych B arrives outpatient at the clinic psych outpatient clinicUTILIZED EMERGENCY UTILIZED ROOM EMERGENCY & Heinrealizes that he Hehas realizes hours thattohewait hasfor5 the hours to wait for INPATIENT the early the morning. early in 5the morning. ACUTE PSYCHIATRIC INPATIENT ACUTE WARD PSYCHIA minibus to go home minibus so hetowalks go home to thesomarket he walks to the market to get lunch. Thetomarket get lunch. is runThe by the market long-is run by the longpatients. term psychiatric patients. He term waitspsychiatric outside of He reception waits outside in the waiting of reception in the waiting room. room. He saw a postedHe for saw a class a posted on managing for a class on managing depression and attends depression it. and attends it. He sees a psychiatric Heofficer sees aafter psychiatric only waiting officer after only waiting an hour. an hour. Patient B is able Patient to take aB minibus is able tohome take after a minibus home after changing his medicine changing andhis learning medicine howand to learning how to The clinical officer determines The clinicalthat officer his determines current that his current better manage hisbetter depression. manage his depression. anti-depression is not anti-depression working and prescribes is not working and prescribes him a different one. him a different one.

UTILIZED PSYCHIATRIC UTILIZED OUTPATIENT PSYCHIATRIC OUTPATIENT CLINIC CLINIC

There is a long waitThere to seeisthe a long clinical waitofficers to see the clinical officers so she decides to attend so shea decides nearby education to attend a nearby education Patient A is able to Patient take aA minibus is able tohome take after a minibus home after session while she waits. session while she waits. addressing her physical addressing and her mental physical health. and mental health. At that session she At learned that session about the shecauses learned about the causes of mental illness andofitmental helpedillness her break and down it helped her break down the stigma she carried. the stigma she carried.

4 4

4:30pm 4:30pm

Patient B is able to take Patient a minibus B is ablehome to take after a minibus home after changing his medicine changing and learning his medicine how toand learning how to better manage his depression. better manage his depression.

She goes to the dispensary She goesand to the waits dispensary in a long and waits in a long line. She receives her line.medicine. She receives her medicine.

Patient A is able to take Patient a minibus A is ablehome to take after a minibus home after addressing her physical addressing and mental her physical health. and mental health.

8:30am 8:30am 9:30am 9:30am

6: 7:

1:00pm 1:00pm 2:00pm 2:00pm 8:30am 8:30am 2:30pm 2:30pm 9:30am 9:30am 3:30pm 3:30pm 1:00pm 1:00pm PATIENTPATIENT F F MAN, 27MAN, 27 DEPRESSION, DEPRESSION, 2:00pm 2:00pm ANXIETYANXIETY - HIV - HIV RELATED RELATED 2:30pm 2:30pm 3:30pm 3:30pm

8: 9: 6:3 11 7:3 12 8:0 PATIENTPATIENT G 1:3G WOMAN,WOMAN, 37 SCHIZOPHRENIC SCHIZOPHRE 9:0 1: 11: 6: 12: 7:

7:30am 7:30am

Patient E shows Patient up to theE outpatient shows up to psychiatric the outpatient psychiatric ward and asked about ward and theirasked addiction about treatment their addiction treatment Soon after, he is Soon meeting after, withheaisclinical meeting officer with a clinical officer to discuss treatment. to discuss They recommend treatment. They a 72recommend a 72 hour detox in thehour shortdetox term in stay theand short then term stay and then outpatient meetings. outpatient For a few meetings. weeks,For he awould few weeks, he would need to come to need the clinic to come for the to day the clinic and then for the day and then slowly his treatment slowly timehiswill treatment lessen. time will lessen.

8:30am 8:30am PATIENT PATIENT E E MAN, 19 MAN, 19 ADDICTION ADDICTION

Soon after, he is meeting Soon after, with ahe clinical is meeting officerwith a clinical officer to discuss treatment.toThey discuss recommend treatment.a They 72 recommend a 72 hour detox in the short hourterm detox stay in and the short then term stay and then He starts intensive He therapy starts and learns therapy coping andweeks, learns he coping outpatient meetings. outpatient For a fewintensive meetings. weeks, he For would a few would strategies strategies him to stop drinking to help him forclinic good. stopfor drinking good. need to cometotohelp theneed clinic forcome the day to the and then the dayforand then slowly his treatmentslowly time will hislessen. treatment time will lessen.

Later Later

PATIENTPATIENT E E MAN, 19MAN, 19 ADDICTION ADDICTION

10:00am 10:00am

UTILIZED PSYCHIATRIC UTILIZED OUTPATIENT PSYCHIATRIC OUTPATIENT CLINIC & ADDICTION CENTER CLINIC & ADDICTION CENTER

136

He is ready to beHe discharged is ready toand beisdischarged evaluated and is evaluated by a clinical officer byknowledgeable a clinical officerinknowledgeable mental in mental health. The doctor health. notices The signs doctor of depression notices signs of depression and anxiety as a and result anxiety of having as aHIV. result of having HIV.

PATIENT PATIENT F F After deciding to After detox,deciding Patient to E is detox, takenPatient to E is taken to MAN, 27 MAN, 27 shower and change shower into hospital and change clothing. into hospital His clothing. His belongings are stored belongings for hisare release. stored for his release. DEPRESSION, DEPRESSION, Patient E shows up Patient to the outpatient E shows up psychiatric to the outpatient psychiatric ward and asked about ward their andaddiction asked about treatment their addiction treatment ANXIETY ANXIETY - HIV - HIV He settled into hisHeroom settled andinto spends his room the next and spends the next 72 hours detoxing. 72He hours is indetoxing. too muchHe pain is intotoo much pain to RELATED RELATED take part in any counseling take part inorany activities. counseling or activities.

10:00am 10:00am 7:30am 7:30am 2:30pm 2:30pm 8:30am 8:30am 3 Days 3 Days

UTILIZED PSYCHIATRIC UTILIZED OUTPATIENT PSYCHIATRIC OUTPATIENT CLINIC & ADDICTION CLINIC CENTER & ADDICTION CENTER

Patient F is in thePatient hospital F is forinHIV therelated hospital for HIV related complications complications

After deciding to detox, AfterPatient deciding E istotaken detox,toPatient E is taken to shower and changeshower into hospital and change clothing. into Hishospital clothing. His belongings are stored belongings for his release. are stored for his release.

2:30pm 2:30pm

He settled into his room He settled and spends into histhe room nextand spends the next 72 hours detoxing. He 72 hours is in too detoxing. much pain He to is in too much pain to take part in any counseling take partorinactivities. any counseling or activities.

3 Days 3 Days He starts intensive therapy He startsand intensive learns coping therapy and learns coping strategies to help him strategies stop drinking to helpforhim good. stop drinking for good. LaterLater

UTILIZED KCH INPATIENT UTILIZED WARD, KCH INPATIENT WARD, PSYCHIATRIC OUTPATIENT PSYCHIATRIC CLINIC OUTPATIENT CLINIC INTEGRATED MEDICAL INTEGRATED MODEL MEDICAL MODEL

Patient F is discharged Patientfrom F is discharged the inpatientfrom wardthe inpatient ward and is referred toand the ispsychiatric referred toclinic. the psychiatric clinic.

PATIENT PATIENT G G WOMAN, WOMAN, 37 3 After checking inAfter and waiting checking outside, in andhe waiting meetsoutside, he meets SCHIZOPHRENIC SCHIZOPHRE with Fa is nurse in hospital aPatient with consultation a nurse room. a consultation room. Patient in the for F isHIV inin the related hospital for HIV related complications

complications

UTILIZED PSYCHIATRIC UTILIZED INPATIENT PSYCHIATRIC INPAT ACUTE WARD ACUTE WARD

The doctor diagnoses The doctor the patient diagnoses with anxiety the patient with anxiety and depression co and morbid depression to HIV.coHemorbid is given to aHIV. He is given a He prescription is ready to be He is ready and toforisbeanti-depressants, evaluated discharged and is evaluated fordischarged anti-depressants, prescription and told to come and told to come by aback clinical by a clinical mental knowledgeable in mental laterofficer in theknowledgeable week back later for aninofficer educational theinweek forclass. an educational class. health. The doctor notices health. signs The doctor of depression notices signs of depression andHe anxiety a result and anxiety having as HIV. adispensary result having goes as to the dispensary He of goes totothe pick up hisofmedicine to pickHIV. up his medicine that he was prescribed that heand wasleaves prescribed the hospital. and leaves the hospital. Patient F is discharged Patient fromF the is discharged inpatient ward from the inpatient ward and is referred to theand psychiatric is referredclinic. to the psychiatric clinic.

After checking in and After waiting checking outside, in and he meets waiting outside, he meets with a nurse in a consultation with a nurse room. in a consultation room.

UTILIZED KCH INPATIENT UTILIZED WARD, KCH INPATIENT WARD, PSYCHIATRIC OUTPATIENT PSYCHIATRIC CLINIC OUTPATIENT CLINIC INTEGRATED MEDICAL INTEGRATED MODEL MEDICAL MODEL

UTILIZED PSYCHIATRIC UTILIZED INPATIENT PSYCHIATRIC INPATI ACUTE WARD ACUTE WARD

The doctor diagnoses Thethe doctor patient diagnoses with anxiety the patient with anxiety and depression co morbid and depression to HIV. Hecoismorbid given ato HIV. He is given a prescription for anti-depressants, prescription forand anti-depressants, told to come and told to come back later in the week back forlater an educational in the weekclass. for an educational class. He goes to the dispensary He goestotopick theup dispensary his medicine to pick up his medicine that he was prescribed thatand he was leaves prescribed the hospital. and leaves the hospital.

PATIENT C MAN, 32 SUICIDE ATTEMPT UTILIZED EMERGENCY ROOM &

hours to wait for the INPATIENT ACUTE PSYCHIATRIC WARD arrives at the psych outpatient clinic e Patient walks toBthe market in the the longmorning. searly run by

Heonwaits outside of reception in the waiting ss managing . room.

He sees a psychiatric officer after only waiting minibus home after an hour. d learning how to sych Patient outpatient B arrives clinic at the psych outpatient clinic sion. early in the morning. The clinical officer determines that his current anti-depression is not working and prescribes him a different one. tion He in waits the outside waiting of reception in the waiting room. He realizes that he has 5 hours to wait for the

minibus to go home so he walks to the market to get lunch. The market is run by the longcer Heafter sees only a psychiatric waiting officer after only waiting term psychiatric patients. an hour.

placed in the seclusion room for his safety.

10:00am 11:00am4:30pm 4:45pm

8:30am PATIENT C 4:30pm 4:30pm MAN, 32 SUICIDE ATTEMPT 10:00am 4:45pm4:45pm 8:30am11:00am 8:30am UTILIZED EMERGENCY ROOM & INPATIENT ACUTE PSYCHIATRIC WARD

depression attends it. ines The that clinical his and officer current determines that his current rking anti-depression and prescribes is not working and prescribes him a different one. Patient B is able to take a minibus home after UTILIZED EMERGENCY ROOMUTILIZED & EMERGENCY ROOM & hours He realizes to wait for the he hasand 5 hours to wait the PSYCHIATRIC changing histhat medicine learning howfortoACUTE INPATIENT INPATIENT WARD ACUTE PSYCHIATRIC WARD e minibus walks manage totothegomarket home so he walks to the market better his depression. storun getbylunch. the longThe market is run by the longterm psychiatric patients.

After the patient is transferred, his family receives The emergency room doctors Theeducational induce emergency vomiting roomtodoctors induce vomiting an class help them understand to rid his body of the pesticides to that hisinbody he of the pesticides that he andridaid his recovery. ingested. ingested.

6:30am 7:30am

l for HIV related

ged and is evaluated edgeable in mental s signs of depression having HIV.

UTILIZED PSYCHIATRIC INPATIENT ACUTE WARD

Patient F is discharged from the inpatient ward l and Patient for HIV Frelated is in the hospital for HIVclinic. related is referred to the psychiatric complications

After checking in and waiting outside, he meets ged He isaready is evaluated toinbe discharged and is evaluated withand nurse a consultation room. edgeable by a clinical in mental officer knowledgeable in mental s health. signs ofThe depression doctor notices signs of depression The doctor patient HIV. with anxiety having and anxiety HIV. diagnoses as a resultthe of having and depression co morbid to HIV. He is given a prescription for anti-depressants, and told to come om Patient the inpatient F is discharged ward from the inpatient ward back later in the week for an educational class. chiatric and is clinic. referred to the psychiatric clinic.

He goes to the dispensary to pick up his medicine that he was prescribed and leaves the hospital. ting After outside, checking he meets in and waiting outside, he meets tion withroom. a nurse in a consultation room.

UTILIZED PSYCHIATRIC INPATIENT ACUTE WARD

yHe to pick goesuptohis themedicine dispensary to pick up his medicine ndthat leaves he was the prescribed hospital. and leaves the hospital.

UTILIZED INPATIENT GERIATRIC WARD

After taking her information, she is brought to After the group therapy session, she decides to the cafeteria for lunch. stay outside and hang around the rec room to Patient D arrives at the psychiatric Patient arrives at the psychiatric hospital pray during her afternoon free timeDhospital via ambulance from the northern via ambulance region offrom the northern region of Malawi. Malawi. She was then brought to her room in the Patient D heads to the cafeteria andward sits with introduced her geriatric to herroom roommates. She was brought to a consultation She wasroom brought andto a consultation and roommates. They don’t talk much but seem relaxed. the nurses take down her information, the nurses take history, down her information, history, and vitals. and vitals. After settling in, a psychiatrist comes to evaluate decide After sitting in the dayroom,her. sheThey receives herto take a walk outside of her After taking herheads information, After she is brought information, to comfortable. she is brought to room so sheher is more medicine and back to hertaking room. the cafeteria for lunch. the cafeteria for lunch.

She is taken back to her room and then taken She heads to her room andtogets ready for bedsession outside. a group therapy She was then brought to her Sheroom wasinthen the brought to her room in the geriatric ward and introduced geriatric to herward roommates. and introduced to her roommates. After the group therapy session, she decides to stay outside and hang around the rec room to After settling in, a psychiatrist Aftercomes settling toher in, evaluate a psychiatrist pray during afternoon free comes time to evaluate her. They decide to take a her. walkThey outside of her decide to take a walk outside of her room so she is more comfortable. room so she is more comfortable. Patient D heads to the cafeteria and sits with her roommates. They don’t talk much but seem relaxed. She is taken back to her room She and is taken thenback takento her room and then taken to a group therapy sessiontooutside. a group therapy session outside. After sitting in the dayroom, she receives her medicine and heads back to her room. After the group therapy session, After the shegroup decides therapy to session, she decides to stay outside and hang around rec room to around the rec room to staythe outside and hang pray during her afternoon free praytime during her afternoon free time She heads to her room and gets ready for bed

Patient G wakes up. She bathes and dressed before breakfast. She eats her breakfast and is given her morning medicine.

She is given some time to relax in the morning which she spends outside. Patient G then attends her morning group therapy session where she sets her goals and goes for a walk outside.

Patient the cafeteria Patient and D heads sitswith with toher her the cafeteria and sits with her PatientDHheads had atoseizure while cooking roommates. They don’t talk muchforbut seem Theyrelaxed. don’t talk much but seem relaxed. mom and was brought to roommates. KCH treatment. After the dayroom, After she sitting receives in the herdayroom, she receives her The sitting doctorintreats the burns in the outpatient medicine heads medicine andward heads back to her room. clinic andand refers the back child to to her the room. psych to treat her epilepsy. Sheheads is seen psychiatric hospital where sheand gets ready for bed She to in hertheroom andShe getsheads readytofor herbed room is referred again to the neuro department to treat the cause of her seizures

PATIENT H CHILD, 8 EPILEPSY

2:00pm 4:00pm9:30am 10:00am

Patient H is seen in the neuro department and is prescribed a medicine to help with her seizures.

UTILIZED KCH OUTPATIENT CLINIC, PSYCHIATRIC INPATIENT

Patient G wakes up. She bathes andPEDIATRIC dressed WARD & NEURO DEPARTMENT INTEGRATED MEDICAL MODEL before Following the group session, she breakfast. checks in with her doctor and receives therapy. The therapy session brings up a traumatic past event. She eats her breakfast and is given her morning medicine. She goes to lunch visibly upset but is refusing to talk to her nurse.

Patient H had a seizure while cooking with her She goes to the dispensarymom to pick herbrought medicine andupwas to KCH for treatment. with her mom and they leave the hospital.

12:00pm 9:30am9:30am 2:00pm 10:00am10:00am 4:00pm 12:00pm 12:00pm PATIENT H PATIENT H CHILD, 8 CHILD, 8 2:00pm2:00pm EPILEPSY EPILEPSY 4:00pm4:00pm

Shevoices is given someher time After lunch, she starts to hear telling to to relax in the morning Patient G wakes up.behavior She bathes Patient and G wakes dressed up. She bathes and dressed which she spends outside. hurt herself and her becomes altered. before breakfast. before breakfast.

UTILIZED PSYCHIATRIC INPATIENT UTILIZED PSYCHIATRIC INPATIENT ACUTE WARD ACUTE WARD

patient The doctor with diagnoses anxiety the patient with anxiety d and to HIV. depression He is given co morbid a to HIV. He is given a essants, prescription and told for anti-depressants, to come and told to come an back educational later in theclass. week for an educational class.

She was brought to a consultation room and the nurses take down her information, history, She is taken back to her room and then taken and vitals. to a group therapy session outside.

Patient C spends the day being Patientevaluated C spendsand the day being evaluated and after the medicine has stabilized after the hismedicine suicidal has stabilized his suicidal idealation, he is transferredidealation, to the acute he ward is transferred to the acute ward and continues therapy. and continues therapy.

8:00am 9:00am 11:00am6:30am 12:00pm7:30am 1:00pm 8:00am PATIENT G 6:30am 6:30am WOMAN, 37 SCHIZOPHRENIC 1:15pm 7:30am9:00am 7:30am 6:00pm11:00am 8:00am 8:00am PATIENT G PATIENT G 7:00pm WOMAN, 37WOMAN, 37 12:00pm SCHIZOPHRENIC SCHIZOPHRENIC 9:00am9:00am 7:30pm1:00pm 11:00am11:00am 1:15pm 12:00pm12:00pm 6:00pm PATIENT G WOMAN, 37 SCHIZOPHRENIC

Patient F is in the hospital for HIV related patient with anxiety complications d to HIV. He is given a essants, and told to come an educational class. He is ready to be discharged and is evaluated by a clinical officer knowledgeable in mental y to pick up his medicine health. The doctor notices signs of depression nd leaves the hospital. and anxiety as a result of having HIV.

Patient D arrives at the psychiatric hospital After settling in, a psychiatrist comes to evaluate her. They decide to take a via walkambulance outside offrom her the northern region of Malawi. room so she is more comfortable.

After the patient is transferred, Afterhis thefamily patientreceives is transferred, his family receives an educational class to help anthem educational understand class to help them understand UTILIZED INPATIENT GERIATRIC UTILIZED WARD INPATIENT GERIATRIC WARD and aid in his recovery. and aid in his recovery.

minibus Patient Bhome is able after to take a minibus home after dchanging learning how his medicine to and learning how to sion. better manage his depression.

ting outside, he meets tion room.

She was then brought to her room in the geriatric ward and introduced to her roommates.

Patient C spends the day being evaluated and stabilized his suicidal Patient C is stabilized and after Patient after the spending Cmedicine is stabilized the hasand after spending the idealation, ishe transferred the acute ward night in the main hospital for night observation, in thehe main hospital is fortoobservation, he is and continues therapy. transferred to the psychiatric transferred hospital. to Hethe is psychiatric hospital. He is placed in the seclusion room placed for his in the safety. seclusion room for his safety.

10:00am10:00am 11:00am11:00am

ss Heonsaw managing a posted for a class on managing . depression and attends it.

om the inpatient ward chiatric clinic.

12:45pm 1:00pm9:00am 2:00pm9:20am 12:00pm PATIENT D 4:30pm 9:00am 9:00am WOMAN, 63 12:45pm DEMENTIA 6:00pm 9:20am9:20am 1:00pm 8:00pm12:00pm 12:00pm PATIENT D PATIENT D WOMAN, 63WOMAN, 63 2:00pm 9:00pm 12:45pm 12:45pm DEMENTIA DEMENTIA 4:30pm 1:00pm1:00pm 6:00pm 2:00pm2:00pm 8:00pm 4:30pm4:30pm 9:00pm 6:00pm 9:30am6:00pm 8:00pm 10:00am8:00pm 9:00pm 12:00pm9:00pm

Patient C is stabilized and after spending the night in the main hospital for observation, he is transferred to the psychiatric hospital.room He is Patient C presents at the emergency Patient C presents room at the emergency the seclusion room for his safety. after an attempted suicide placed after attempt. aninattempted suicide attempt.

PATIENT C PATIENT C MAN, 32 MAN, 32 SUICIDE ATTEMPT SUICIDE ATTEMPT

He saw a posted for a class on managing

PATIENT D WOMAN, 63 DEMENTIA

After the patient is transferred, his family receives an educational class to help them understand UTILIZED INPATIENT GERIATRIC WARD and aid in his recovery. Patient C presents at the emergency room after an attempted Patient C spends the day being evaluated andsuicide attempt. after the medicine has stabilized his suicidal idealation, he is transferred to the acute ward and continues therapy. The emergency room doctors induce vomiting to rid his body of the pesticides that he ingested.

PATIENT ANALYSIS HOSPITAL DESIGN

ines that his current rking and prescribes

attends her morning group therapy The doctor decides to havePatient her goGinthen the seclusion session she setsand her is goals and for roomeats so that doctorsand can herbreakfast more She her the breakfast She ismonitor given eatswhere her morning given hergoes morning amedicine. walk outside. closely. medicine. Patient G stays in the seclusion roomthe until dinner Following group session, she checks in with but she eats away from theher other patients. doctor and receives therapy. The therapy session brings up atime traumatic past event. She is given some time to She relaxisingiven the morning some to relax in the morning

PATIENT H CHILD, 8 EPILEPSY

UTILIZED KCH OUTPATIENT CLINIC, PSYCHIATRIC INPATIENT PEDIATRIC WARD & NEURO DEPARTMENT INTEGRATED MEDICAL MODEL

which she spends which sheconsult spendsroom outside. She checks in withoutside. the nurse in the where she tells the nurse that thoughts Shethe goes to lunchhave visibly upset but is refusing to gone away. talk to her nurse. Patient G then attends herPatient morningGgroup then attends therapyher morning group therapy session where she sets hersession goals and where goes sheforsets her goals and goes for nurse allows her to relax in the day room aThe walk outside. a walk outside. UTILIZED KCH OUTPATIENT CLINIC, UTILIZED KCH OUTPATIENT CLINIC, After lunch, she starts to hear voices telling PSYCHIATRIC her to INPATIENT PSYCHIATRIC INPATIENT until it’s time for bed. PEDIATRIC PEDIATRIC WARD & NEURO DEPARTMENT hurt herself and her behavior becomes altered.WARD & NEURO DEPARTMENT MEDICAL MODEL INTEGRATED MEDICAL MODEL Following the group session, Following she checks the group in withsession, she checks INTEGRATED in with her doctor and receives therapy. her doctor The and therapy receives therapy. The therapy The doctor decides have herpast go event. in the seclusion session brings up a traumatic session past brings event. up a to traumatic room so that the doctors can monitor her more closely. She goes to lunch visibly upset She goes but istorefusing lunch visibly to upset but is refusing to talk to her nurse. talk to her nurse. Patient G stays in the seclusion room until dinner but she eats away from the other patients.

The doctor treats the burns in the outpatient clinic and refers the child to the psych ward to treat her epilepsy.

She is seen in the psychiatric hospital where she is referred again to the neuro department to treat the cause ofwith her seizureswhile cooking with her Patient H had a seizure while Patient cooking H had a seizure her mom and was brought to KCH momfor and treatment. was brought to KCH for treatment. Patient H is seen in the neuro department and is prescribed a medicine to help with her seizures. The doctor treats the burnsThe in the doctor outpatient treats the burns in the outpatient clinic and refers the child toclinic the psych and refers wardthe child to the psych ward to treat her epilepsy. to treat her epilepsy. She goes to the dispensary to pick up her medicine with her mom and they leave the hospital. She is seen in the psychiatric Shehospital is seen where in the psychiatric she hospital where she is referred again to the neuro is referred department againtototreat the neuro department to treat the cause of her seizures the cause of her seizures Patient H is seen in the neuro Patient department H is seenand in the neuro department and is prescribed a medicine toishelp prescribed with heraseizures. medicine to help with her seizures.

She goes to the dispensaryShe to pick goesuptoher themedicine dispensary to pick up her medicine with her mom and they leave withthe herhospital. mom and they leave the hospital.

137

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CENTER PATH PERSPECTIVE139

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PEDIATRIC WARD PERSPECTIVE141

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ACUTE WARD PERSPECTIVE143

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APPENDIX

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REFLECTIONS

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Rachel Meier The process for this research started a few months prior to the design project to understand the cultural and community needs of Malawi. Both precedents and anecdotes were collected to analyze the social, cultural, and environmental aspects of the country. The work to be done for Kamuzu Central Hospital required a complex grasp on not only hospital design, but how to also accomplish those designs with sensitivity and compassion. Spending the last few months solely focusing on psychiatric care for KCH became a complex framework of education, distillation, advocacy, and creativity. At the very start of researching, it became very clear that proper design documentation and legislation do not exist for psychiatric care. This was not just an issue in Sub-Saharan Africa, but the entire world. Goals then shifted towards breaking down key components of hospital design, psychiatric care, and compassion in order to peace them back together in a way that is appropriate to the culture and function in Malawi. The first step to accomplish that was to understand the user groups found in psychiatric hospitals as well as some of their daily needs and expectations. This documentation was clearly stated but typically from a perspective outside of Africa. This is where it was pivotal to collect as many anecdotes as possible from local doctors and medical professions, as well as others who have lived in the area. Their insight on the daily life and culture of Malawians was essential in filling the gaps created by standard research methods. While some precedents do exist around psychiatric care and its design in Sub-Saharan Africa, this project can become a valuable collection of research and analysis for future development to be based on. The unique perspective of not just designing a space for the statistics and facts found, but that focuses on the human experience and impact of destigmatizing sensitive care environments. If I were to continue this project, I would prioritize the development of the standard precedent for not simply a design, but for a research and design process. Spatial requirements should still continue to be set and regulated by the government due to mental illnessâ&#x20AC;&#x2122;s prevalence in the world, but in a way that can be easily applied to a variety of cultures and environmental conditions. A framework for change should continue to be developed that ensures the staggering numbers of patients that need this resource have it, and in a way that only leads to positive growth for him or herself, the community, and society as a whole.

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Anna Ayik Over the course of two semesters, time was spent understanding not only Kamuzu Central Hospital design but also the culture of people of Malawi and the needs they have for their healthcare system. Communicating with numerous individuals that have a connection to Malawi, compassionate medicine, or healthcare design allowed for an understanding of the place, culture, and program type. The anecdotal stories and information shared, coupled with the medical literature that was reviewed allowed an deep understanding each program type. By the end of the research phase, the userâ&#x20AC;&#x2122;s architectural needs were understood and could be translated spatially. Spending a little longer researching and understanding the program list through adjacency diagrams was extremely beneficial for the design. There was no clear documentation or legislation for mental health in a similar context. Because of the lack of contextual examples, the establishment of clear criteria for each program group and type enabled the decisions to be made with absolute reason rather than in a speculative nature. Speaking with Dr. George Stewart, a psychiatrist who worked in Blantyre, midway through the spring semester confirmed many aspects of the new framework plan of the hospital while clarifying the remaining aspects that were not clear yet. One of the most important aspects of the research was the care models. Through the integrated medical model, compassionate care was introduced. The positive effects of compassionate care on patients in any healthcare setting makes it ideal to be implemented in the design of a psychiatric hospital. The implementation of compassion into architecture drove a lot of the decisions on the framework plan as well as more details in each impatient ward. With the framework of the hospital set, the next stage in the process would be to understand the building assemblies. Because of the scope and complexity of the psychiatric hospital, there was not enough time to get to a more intricate detail in the design and construction of the building but understanding natural ventilation and how the threshold between inside and outside work is important to uphold the concept of the hospital. Overall, Kamuzu Psychiatric Hospital responds to the needs of its users by creating an environment to help its patients heal. Each program type was taken into consideration and the spaces for the patients exist inside and outside. The building and landscape can aid the medical professionals in helping patients with severe mental illnesses move beyond the hospital and back into society.

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Raymond Bracy We began our research intending to learn about how psychiatric patients are cared for so we could support those care models with the built environment. Our intentions quickly switched when we discovered that there were no standard models of care for psychiatric patients in Malawi. That revelation made us realize that if we were going to design a psychiatric hospital that would properly care for its patients, we would have to start from scratch. We began researching care models that other countries used to see which would be the most effective in caring for patients in Malawi. The model we chose was an integrated medical model that combines typical hospital care with psychiatric care. This this model patients who present to the hospital for a physical illness are referred to the psychiatric hospital if a possible mental illness is detected. This would hopefully help break down the stigma against psychiatric care and the hesitation Malawians have to receive psychiatric treatment. While conducting this research we came across the idea of compassionate care. The idea was simple, giving doctors an opportunity to connect with their patients on an interpersonal level results in positive patient outcomes. This became the basis for all of out future work. We knew that the key element to compassionate care was connecting doctors to patients, so we challenged ourselves to see if there were ways to incorporate compassionate care into our building and landscape designs. Akin to what doctors must do to deliver this care, we had to understand as much as possible about the patients we were serving to create positive environments for them. We began talking to psychiatrists who worked in Malawi and other countries with resource disparities to see what both patients and doctors looked for in a psychiatric facility. Conversations with these medical professionals revealed to us that due to the variation in illnesses, length of stay, age, and type of care received each user group in the hospital would require a different built and landscape solution to support their healing. Responding to this, we developed a hospital ward building module that includes patient rooms, a core for doctor movement, and a courtyard. We proposed that these elements could be modified in a number of different ways to support the patients that would be present in the ward. The module we developed is the basis for implementing compassionate care in the hospital, and the moduleâ&#x20AC;&#x2122;s adaptability allows for patients to receive the type of care they require while they are in the facility. We demonstrated these modifications in our proposal for Kamuzu Central Psychiatric Hospital.

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Endnotes 1 Chorwe-Sungani, G., Jere, D. L., Sefasi, A., & Kululanga, L. (2015). A historical perspective of 50 years of mental health services in Malawi. The Society of Malawi Journal,68(2), 31-38. Retrieved February 8, 2019 2 Barnett, B. S., Kusunzi, V., Magola, L., Borba, C. P., Udedi, M., Kulisewa, K., & Hosseinipour, M. C. (2018). Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi. Social Psychiatry and Psychiatric Epidemiology. 3 The Government of Malawi. (n.d.). National Mental Health Policy(Malawi) 4 Chitete, S. (2017, October 15). Funding woes hit KCH hard. Retrieved from https://mwnation. com/funding-woes-hit-kch-hard/ 5 Malawi, Ministry of Health, Office of the Ombudsman. (2017). Out of Sight, Out of Mind. Lilongwe, Malawi. 6 Mental Illness and the Family: Is Hospitalization Necessary. (2013, November 09). Retrieved from http://www.mentalhealthamerica.net/is-hospitalization-necessary 7 WHO. (2014). Malawi - Mental Health Atlas country profile 2014. Retrieved February 8, 2019, from https://www.who.int/mental_health/evidence/atlas/profiles-2014/mwi.pdf?ua=1 8 Delle, S. (2017, February). Thereâ&#x20AC;&#x2122;s no shame in taking care of your mental health. Speech presented at TEDLagos Idea Search in Nigeria, Lagos. 9 Barnett, B. S., Kusunzi, V., Magola, L., Borba, C. P., Udedi, M., Kulisewa, K., & Hosseinipour, M. C. (2018). Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi. Social Psychiatry and Psychiatric Epidemiology. 10 Udedi, M., Stockton, M. A., Kulisewa, K., Hosseinipour, M. C., Gaynes, B. N., Mphonda, S. M., . . . Pence, B. W. (2018). Integrating depression management into HIV primary care in central Malawi: The implementation of a pilot capacity building program. BMC Health Services Research, 18(1). doi:10.1186/s12913-018-3388-z 11 Vettori, A. (2019, February 2). Cultural Competency and Homelessness. Lecture presented at 2019 Humanism in Medicine Conference in Thomas Jefferson University, Philadelphia. 12 Tinland, A., Fortanier, C., Girard, V., Laval, C., Videau, B., Rhenter, P., . . . Auquier, P. (2013). Evaluation of the Housing First program in patients with severe mental disorders in France: Study protocol for a randomized controlled trial. Trials,14(1), 309. doi:10.1186/1745-6215-14-309 13 Alem, A., Jacobsson, L., & Hanlon, C. (2008). Community-based mental health care in Africa: Mental health workersâ&#x20AC;&#x2122; views. World Psychiatry,7(1), 54-57. doi:10.1002/j.2051-5545.2008. tb00153.x 14 Rensburg, A. J., & Fourie, P. (2016). Health policy and integrated mental health care in the SADC region: Strategic clarification using the Rainbow Model. International Journal of Mental Health Systems,10(1). doi:10.1186/s13033-016-0081-7

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15 Almony, J. (2019, February 1). Dr. Almony Interview [Telephone interview]. 16 Stewart, G. (2019, February 6). Dr. Stewart Interview [Telephone interview]. 17 Trzeciak, S. (2018, June 5). Dr. Stephen Trzeciak: How 40 Seconds of Compassion Could Save a Life. Speech presented at TEDx Talks in Penn, Philadelphia. Retrieved from https://www. youtube.com/watch?v=elW69hyPUuI 18 Trzeciak, S. (2018, June 5). Dr. Stephen Trzeciak: How 40 Seconds of Compassion Could Save a Life. Speech presented at TEDx Talks in Penn, Philadelphia. Retrieved from https://www. youtube.com/watch?v=elW69hyPUuI 19 Jeffrey, D. (2016). Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? Journal of the Royal Society of Medicine, 109(12), 446–452. https://doi.org/10.1177/0141076816680120 20 Trzeciak, S. (2018, June 5). Dr. Stephen Trzeciak: How 40 Seconds of Compassion Could Save a Life. Speech presented at TEDx Talks in Penn, Philadelphia. Retrieved from https://www. youtube.com/watch?v=elW69hyPUuI 21 Barnett, B. S., Kusunzi, V., Magola, L., Borba, C. P., Udedi, M., Kulisewa, K., & Hosseinipour, M. C. (2018). Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi. Social Psychiatry and Psychiatric Epidemiology. 22 Lappin, John. “Can Design Help Shrink the ‘Empathy Deficit’?” Design Council, The Design Council, 17 Jan. 2018, www.designcouncil.org.uk/news-opinion/can-design-help-shrink-empathydeficit. 23 Jeffrey, D. (2016). Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? Journal of the Royal Society of Medicine, 109(12), 446–452. https://doi.org/10.1177/0141076816680120 24 Trzeciak, S. (2018, June 5). Dr. Stephen Trzeciak: How 40 Seconds of Compassion Could Save a Life. Speech presented at TEDx Talks in Penn, Philadelphia. Retrieved from https://www. youtube.com/watch?v=elW69hyPUuI 25 Lappin, John. “Can Design Help Shrink the ‘Empathy Deficit’?” Design Council, The Design Council, 17 Jan. 2018, 26 Trzeciak, S. (2018, June 5). Dr. Stephen Trzeciak: How 40 Seconds of Compassion Could Save a Life. Speech presented at TEDx Talks in Penn, Philadelphia. Retrieved from https://www. youtube.com/watch?v=elW69hyPUuI 27 Udedi, Kusunzi, V., Mtonga, J., Makhalira Chenyama, M., Tepeka, C., Chipa, M., . . . Galimoto. (2017). Minutes of the Meeting Held on 23/06/2017 at Psychiatric Unit (KCH)(Meeting Minutes). Lilongwe.

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28 Stewart, G. (2019, February 6). Dr. Stewart Interview [Telephone interview]. 29 Csipke, E., Papoulias, C., Vitoratou, S., Williams, P., Rose, D., & Wykes, T. (2016). Design in mind: Eliciting service user and frontline staff perspectives on psychiatric ward design through participatory methods. Journal of Mental Health,25(2), 114-121. doi:10.3109/09638237.2016.1139 061 30 Trzpuc, S. J., Wendt, K. A., Heitzman, S. C., Skemp, S., Thomas, D., & Dahl, R. (2016). Does Space Matter? An Exploratory Study for a Childâ&#x20AC;&#x201C;Adolescent Mental Health Inpatient Unit. HERD: Health Environments Research & Design Journal,10(1), 23-44. doi:10.1177/1937586716634017 31 Stewart, G. (2019, February 6). Dr. Stewart Interview [Telephone interview]. 32 Almony, J. (2019, February 1). Dr. Almony Interview [Telephone interview]. 33 Rensburg, A. J., & Fourie, P. (2016). Health policy and integrated mental health care in the SADC region: Strategic clarification using the Rainbow Model. International Journal of Mental Health Systems,10(1). doi:10.1186/s13033-016-0081- 34 Stewart, G. (2019, February 6). Dr. Stewart Interview [Telephone interview]

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SCRIPT

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Kamuzu Central Psychiatric Hospital Presentation Script Title: Mental health is defined as one’s collective emotional, psychological, and social well-being. It affects thoughts, feelings, and actions both on an individual level and in relation to others. While this presents itself different for each person, it is still a global issue. Today we will be introducing the realm of mental health and psychiatric care as it relates to Malawi, Africa. Research Question: Our intent for this project is a two-fold approach of researching and implementing a psychiatric care model in our case study country of Malawi. Our in-depth inventory process allows us to spatially address the question of how design and compassion can positively impact patients in Malawi’s psychiatric healthcare system. Global Mental Health: To understand why we chose to address mental health, the global stage must be set. Worldwide, mental illnesses cause the greatest amount of economic burden. Over the next two decades, it is estimated that 35% of global economic loss will be a direct result of mental illness and the resulting unemployment and physical ailments. Governments around the world must begin prioritizing larger investments into their psychiatric care sectors. Mental Health in Malawi: One of those government bodies is the Ministry of Health in Malawi. The long history of mental illness in Malawi was not supplemented with formal mental health facilities or legislative recommendations until the 1950s. Even still, the country’s only public mental hospital is found in the very southern city of Zomba. As well, one of the only centrally-located facilities closed in 2017 due to poor conditions, leaving the majority of the country’s mental health patients underserved. The Social Condition: In addition to resource disparities, Malawi’s social context affects the

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percentage of people that receive necessary care. There have been recent movements to regulate healthcare in a way that introduces universal access. This must also include more educational outlets because a social stigma of mental illnesses being brought on by the wrath of God or witchcraft acts as a fracturing force in communities. Universal access can not be utilized efficiently if patients fear not being welcomed back into their community for seeking help and treatment. Compassionate Care: One method of combating that stigma is the reintegration of compassion into the healthcare system. Roughly 70% of opportunities for care providers to be compassionate towards patients are missed and that is scientifically proven to decrease patient adherence and the rate of healing. It only takes 30 to 60 seconds to act compassionately and the impact made on patients ripples far beyond in communities and society. The investment of an extra minute into patient care by staff in conjunction with spaces that encourage positive interaction will help shift the mental health narrative from one of isolation to one of inclusion. Care Delivery Models: Consequently, an appropriate model for that care to be delivered must be identified. A variety of existing care models were analyzed for their resource demands and efficiency in providing access to appropriate treatment. The selected path of care is an integrated medical model that implements psychiatric care wards into existing hospital and treatment programs. This would run parallel to a community based model that sends patients to the hospital from local clinics. Psychiatric Hospital Design: With that research, we transitioned into developing ways that social systems, compassion, and integrated care can be amended and reinforced through spatial interventions. We established program adjacencies and spatial requirements to be implemented into a case study at Kamuzu Central Hospital, a referral hospital in the capital city of Malawi. KCH Site Plan: Last semester, we developed a 20 year framework plan to address the growing population and resource needs of the hospital. Portions of our plan were dedicated to future development where programs like a psychiatric hospital could one day be present. Given the need for this program in Lilongwe, we elected KCH as the suitable site for our case study. 158

Selected Site: The site on which we chose to develop our program is located on the eastern edge of KCH and provides ample opportunities for communication to the remainder of the hospitalâ&#x20AC;&#x2122;s programs. It is also located near the proposed Orthopaedic and Neurosurgery ward and existing HIV treatment center to encourage education across program types. Hospital Program: The hospital provided a list of program requirements found at the recently closed-down psychiatric unit at Bwaila. The necessary users were broken down into outpatient, administration, and inpatient typologies with amended assets to account for the best possible patient experience. Program Adjacencies: Those program types were studied to discover critical adjacencies and organization patterns. Priorities manifested around streamlining staff and resources, providing various means of treatment, and allowing patient and staff access to outdoor spaces. Spatial Requirement Categories: With that in mind, we studied the spatial requirements of the program to identify critical elements and their organization. Four categories were developed to help understand spatial needs: patient safety, patient comfort, patient interaction, and outdoor space. Safety and Comfort: The most important elements in the design of psychiatric hospitals are those that mitigate any risk of harm. Each psychiatrist we interviewed stressed the importance of making all patient spaces visible from a central nurseâ&#x20AC;&#x2122;s station. This is also supplemented with comfortable patient rooms that allow for privacy and confidentiality in a fairly visible living arrangement. Providing patients with a reasonable amount of freedom will encourage trust of the staff and environment. Outdoor Spaces and Interaction: While most patient rooms limit the number of patients in them, there should still be regular interaction with small groups. Originally, these community spaces were realized as indoor rooms with tables and chairs until we address the cultural appropriateness of that decision. Instead, it is stressed that the majority of group and individual therapy can exist in an outdoor setting 159

that is more familiar to the patients. Guiding Principles: These concepts led to the development of six guiding principles that would drive all key design decisions. Each user group would experience these concepts at a different intensity, but they are essential nonetheless to overall patient satisfaction, healing, and adherence. They are: independence, consciousness, connectedness, purpose, physical activity, and rest. Research Question: The next step of our process was to take these integrated and compassionate care model concepts and apply them to design interventions. These interventions span the scale of the individual user, the unique wards, and the organization of a multitude of those wards. User Groups: Starting with the scale of the individual user, the following were studied: acute, geriatric, rehab, adolescent, pediatrics, addiction, infirmary, and outpatient. Levels of care on campus are determined by a variety of factors depending on the user group. Understanding these factors allows us to propose built environment and landscape solutions that support their users. Some of these include the patient’s length of stay, appropriate levels of stimulation, and age. Inpatient Intro: The first set of users exists in our inpatient core. Inpatient Ward Module: All inpatient wards have a central spine that holds program essential to mental health professionals. This allowed the organization of patient room to happen on either side of this spine in order for doctors and nurses to easily serve and see all patients. Clinical Officer Core: The core for the clinical officers contains essential program like the nurse’s stations, consult room, and bathrooms. The central location allows the program to serve both sides of the ward, easing the strain on the hospital’s limited staff and resources. Nurse’s Station: The most important element of that inpatient core becomes the nurse’s station. 160

Patients must be visible from this location at all times to ensure their safety in the ward. Additionally, these stations will service the eight medical professions satisfying the 1:10 patient to staff ratio. Patient Rooms: The next step finds the patient rooms at the edges of the wards. Their angles allow nurses to look directly into the rooms from the nurseâ&#x20AC;&#x2122;s station. Rooms designed for three patients allows them to be in control of how many people they interaction with at one time. Courtyards: All of the previous patient rooms are inward-looking to enclosed courtyards where a majority of patient activity will take place. Enclosing the courtyards in the center of the ward increases the safety of both the patients and staff in the case of patients leaving their wards unattended. The uncovered courtyards are supplemented by covered group therapy spaces and day spaces that can be used when it is raining. Rehab and Geriatric: As we move into the individual wards, slight modifications are made. The rehab and geriatric ward is most similar to our typical module. Their major difference are found in their courtyards. Rehab focuses on the awareness of time passing through various weather conditions and geriatric encourages gentle meandering for passive healing. Pediatric and Adolescent: The main difference in the pediatric ward is present in the classrooms occupying the outer wings of the ward. The courtyard then allows the classroom to extend into the open space while also providing areas for physical activity to release energy in a natural manner. Acute: The acute ward becomes the most different from the typical module to account for the high sensitivity of its patients. There are rooms dedicated to electroconvulsive therapy and seclusion, in addition to a secondary entrance from the addiction center. Inpatient Organization 1: Those wards were then arranged radially around a central outdoor space that encourages both circulation and gathering at a variety of levels. The entrance to each ward is located 90 feet from the center to encourage staff to walk with their patients for roughly 30 seconds. 161

This matrix provides the opportunity for compassionate and gentle integration into a social setting beyond their ward. Inpatient Organization 2: A series of key circulation axes were then established for program and growth to occur beyond the three main ward types. A staff rest area and the infirmary were placed at the end of secondary axes to maintain efficient circulation. Center Circulation 1: Circulation in this area occurs at four different levels to account for various user and staff needs. The first two levels of covered walkway allow for efficient movement while either being a primary corridor with connections to adjacent open spaces or a slimmer path that eases the amount of stimulation for a patient leading up their respective ward. Center Circulation 2: The remaining two levels of uncovered walkways provide a more intimate scale of circulation for small groups or individuals. The first allows for ample access to open space and seating for patients to choose a longer path when it is weather permitting. The final, most personal level is a highly-screened path where staff can introduce a new setting to their patients in a quiet, controlled atmosphere. Outpatient Intro: Once the circulation and organization was thoroughly developed for our inpatient users, we were able to develop the outpatient experience and how patients would be accessing the private program. Outpatient Services: In an outpatient setting, visitors and patients arrive at the entry to the complex where they have their first consultation with a mental health professional. While they wait for their consult, they can gather in one of many civic spaces or attend classes. The dispensary then acts as a transition point either into the inpatient setting, the addiction center, or back out into the community. Outpatient Rendering: The center courtyard allows people to spill out from the consult rooms and wait in an area that is immediately adjacent to the education space. 162

Outpatient Organization: The main axis that the outpatient module creates allows patients to access all necessary program in an efficient way. The balance between gathering and circulation in this setting allows space for conversations that break down stigma. Campus Security: As the campus deals with many sensitive patients, movement throughout the campus is highly controlled to ensure that the patients and public are kept safe. The inpatient checkin buildings separate the public outpatient area from the private inpatient wards. This maintains safety and security by only allowing one controlled main entrance to the center of campus. Center Courtyard Rendering: After understanding these key circulation and organization concepts of the hospital, we wanted to ensure that compassionate care is being implemented on an individual scale by visualizing some of those moments. This is an area in which doctors can walk with their patients to a comfortable outdoor space where they can provide a more personal level of care. Pediatrics Courtyard Rendering: This shows the pediatric ward where young patients are always accompanied by a medical professional while still providing spaces for freedom and exploration. Acute Courtyard Rendering: Similarly, acute patients are trusted to explore levels of isolation or inclusion because they are always visible by the nurseâ&#x20AC;&#x2122;s station at the head of the ward. Closing Aerial Axon: In the context of Malawi and Kamuzu Central Hospital, this design introduces a much-needed standard for psychiatric care. Our site-specific explorations have allowed us to establish examples for integrating compassion into design where cultural sensitivities are present.

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