DISSERTATION REPORT HEALTHCARE ARCHITECTURE: DESIGNING A MULTI-SPECIALTY HOSPITAL INTO THE CITY
Sarayu C | B. ARCH – 8th SEMESTER | January 29, 2015 | SOA, MCE
DISSERTATION REPORT
ABSTRACT OF THE DISSERTATION:
The physical qualities of a hospital building can, in the best case indicate a high level of development and humanity in a given society. The academic purpose of this dissertation is to articulate the accumulated knowledge and dynamics of these qualities as well as the other know-hows deemed relevant to the primary quest of improving the current state of our hospitals. Its pragmatic purpose is to facilitate analysis and to assist in the development of conceptual tools meant to improve the design processes and practices, thereby creating conditions more conducive to high quality architecture. The widely held view is that recent hospital buildings have not responded to modern demands in a satisfactory manner. The hypothesis is made that this view is well-founded, and that the main reason for it is that the architectural quality of the vast majority of these hospitals has not reached the level that should be expected of major public buildings. Recent study claims, and attempts to show, that the underlying reasons for this lack of quality are the shortcomings in the actual design process and in the way design services are procured, as well as in an excessive emphasis on specialization. The study claims that only through combining lessons learnt from the past with a thorough knowledge and insight into the topical discourse can administrators, medical professionals and other user-clients, but above all architects, achieve the design quality that should be expected of our future health care facilities. The present discourse and trends have been examined through research projects and literature researches and a brief shift of paradigm has been analyzed. Along with literature studies, study of present hospitals has been done and studied extensively where the architecture has failed the healthcare industry. Also, how a healthcare building can be modeled after the town it is built in, with the building itself a miniature of a said city, its layout and planning methodology.
AIM OF THE STUDY
Important phases as well as individual buildings are highlighted including several that no longer necessarily carry a particular significance for the future but still form an important link in the totality. The examples that have been included should also not be seen as the “best� hospitals in history, but rather as examples that have played a significant role in the historical continuum. These global 21st century megatrends that are likely to have an effect on the organization of health care and subsequently on the physical facilities are analyzed, as are those medical developments that may change the face of cure and care.
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The notion of a wall-less hospital is brought up as well as two related concepts stemming from the 1950s, “mat building” and “open building” that is trending in the present scenario.. This part also includes a discussion on urban metaphors, the relationships between the city and the hospital. In the second part of the study new health service concepts and organizational models that dominate the current discourse are reviewed and their effect on the facilities analyzed. A critical look is also taken on the present trends in the research into health care facilities, with particular emphasis on evidence-based design and “healing environment “ideologies.
SCOPE OF THE STUDY -
Minimalism, a contemporary trend that is often quoted as having its roots in 1980s, leans heavily on the early Modernist pioneers, such as J. J. P. Oud and Adolf Loos, and at its best represents a continuum of the traditions of international Modernism. The term is here used rather broadly in order to make a distinction between primarily rectilinear and unfussy artefacts and those displaying more flamboyant, expressive features.
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An ever-increasing openness, flexibility and transparency are characteristics of Minimalist Modernism of the new millennium. These attributes are in no conflict with the present trends in hospital design, in fact quite to the contrary.
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The “wow factor” has become a talking point among architects as well as the general public. Buildings that cannot leave anyone indifferent because of their surprising, unusual or even shocking appearance, possess the “wow factor”. The new CAD drawing programs and their applications have made it possible to design (and make) almost anything. The majority of recent major buildings that possess a particularly marked “wow factor “consist of freely flowing, organic forms with few right angles or straight lines.
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”Paradoxically there is a need for isolation, cocooning almost, in perfectly controlled conditions, but also for a healing paradise with lots of people and life around”. This quote presents one of the main dilemmas of hospital design today but is also inspirational.
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It is a fashionable architectural trend to create ‘outside inside’ experiences through different means in order to obscure the borderline between the interior and the exterior. Blurring the boundaries is a trick used by many of the best architects today.
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This happens through the use of double facade systems, shading devices, movable walls and roofs, etc. An internal atrium or garden can seem like an internal space at one time and an external one at another. This kind of techniques has been put into use for a hospital in Barcelona. PAGE 2
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METHODOLOGY
This study will use mixed methods design, which is a procedure for collecting, analyzing and mixing both quantitative and qualitative data at some stage, to understand a problem more completely. The rationale for mixing is that neither quantitative nor qualitative methods are sufficient by themselves to capture the trends. When used in combination, quantitative and qualitative methods complement each other and allow for more complete analysis. Quantitative research relies on numerical data for developing knowledge, such as cause and effect thinking, reduction to specific variables, hypotheses and questions, use of measurement and observation, and the test of theories. Alternatively, qualitative research is “an inquiry process of understanding” where a “complex, holistic picture, analyzes words, reports detailed views of informants, and conducts the study in a natural setting”. In qualitative
research, data is collected from those immersed in everyday life of the setting in which the study
is framed. Data analysis is based on the values that these participants perceive for their world. In a mixed methods approach, the study is based on the knowledge on pragmatic grounds asserting truth is what works. A major tenet of pragmatism is that quantitative and qualitative methods are compatible. Thus, both numerical and text data, collected sequentially or concurrently, can help better understand the problem. While designing a mixed methods study, three issues need consideration: priority, implementation and integration; Priority refers to which method, either quantitative or qualitative, is given more emphasis in the study. Implementation refers to whether the quantitative and qualitative data collection and analysis comes in sequence or in chronological stages, one following another, or in parallel or concurrently. Integration refers to the phase in the research process where the mixing or connecting of quantitative and qualitative data occurs.
RESEARCH OF THE IDEA AND ITS ORIGIN: Introducing a hospital into the city and re-introducing the city into the hospital. The following pages of the compiled dissertation report will contain real-life instants of my ideas carried out in different parts of the globe thereby improvising the healthcare industry by a large margin, mainly in the aspect of architecture, which in a chain has improved all other fields relating to patient-care and research/education. An extensive analyses of the case in point has been made and inferred. “The question of the best size and form a hospital should adopt in order to give psychic help to the sick and at the same time meet all medical requirements, is somewhat akin to the question of how large a city should be, in order to meet the needs of its inhabitants and fulfill its functional requirements.” Said Sir Siegfried Giedion.
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The hospital in question that has been planned in accordance with such a notion initiated in the 14th century. Filippo Brunelleschi’s Ospedale degli Innocenti in Florence is not only the seminal work of the early Renaissance period and one of the most influential buildings in architectural history; it is also an early example of modularity and adaptability. More than simply serving as a model for hospitals it has been an archetype of a classical public building, an urban haven which works masterfully as a mediator between the urban buzz outside and the meditative peace inside its quadrangles.
A MODERN EXAMPLE: St. Olav’s Hospital in Norway, is a recent example of a modern urban pavilion hospital. Its organization is based on target groups and clinical entities, which seems natural considering the physical form of the ensemble. The urban block-based development makes it possible to build a new hospital step by step while the old hospital remains operational at all times. The dimensions of the blocks follow the grain of the grid of the surrounding city structure and are connected to each other by means of the hospital “main streets” on second floor level with bridges crossing the city streets.
LITERATURE STUDY St Olav’s University Hospital – The 21st Century Hospital – An International Perspective on Hospital Architecture. A lot of people who come to visit the hospital say they get the feeling they are in a city there. Firstly because it’s big: an entire block in the neighborhood. But this urban metaphor is the principle throughout the entire project’s layout, which in consequence functions as an urban space – in other words public spaces where people move about on their way to more private spaces that have been attached to a system of networks. It is also present in the interplay between the spaces that open full on to the gallery, the winter garden, and the garden terraces on the outside…urban space penetrates into the hospital as far as possible. Pierre Riboulet, 1988 St Olav’s Hospital in Trondheim has chosen a Cisco Medical-Grade Network to realize its vision of becoming ‘a university hospital at the forefront, focusing on the patient’. The goal is to create a modern hospital facilitating more effective forms of treatment, an improved offering to patients, and a simpler working day for its employees. At St. Olav’s Hospital, Trondheim University Hospital, patient treatment, research and teaching are all completely integrated. The “Operating Room of the Future” (FOR) project is a key factor in the collaboration between Trondheim University Hospital and the Norwegian University of Science and Technology (NTNU).
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At the University Hospital, there is close multidisciplinary activity within the fields of medical technology research, development, technology assessment and clinical studies. The exceptional scientific environment leads to opportunities to create new solutions within medical technology and to stimulate research projects within this field. St. Olav’s Hospital, Trondheim University Hospital, is located in the center of Trondheim and in the vicinity of NTNU. The first clinical centers were completed in 2006, and the entire project will be completed in 2013. The “FOR concept has one dedicated operating room in each center, making six operating rooms in total. These operating rooms are equipped with modern AV-ICT structures, making live transmissions and interactive communication in high-definition quality possible. The main goal of “FOR” is to emerge as an excellent platform for clinical research of the highest quality. Integrated Teaching and Researching with Hospital Care Part of the design specification was an integrated view of research and teaching with hospital care. The layout of St. Olav’s University Hospital has been designed to have research and teaching going hand in hand with patient treatment. The Norwegian University of Science and Technology (NTNU) is closely integrated with the clinic buildings. The hospital site also allows for further development by increasing the height of buildings and adding to the modular campus-style configuration of the developed area.
St. Olav’s Hospital (160 000sqm) located in Trondheim, Norway is the main hospital for Central Norway (one of the five health regions) and functions as a general and local hospital for 200,000 inhabitants in Trondheim. The new hospital will have a catchment population of 650,000 for highly specialized care. Completed in 2014, it has a total area of 223,000 sq. meters, divided into seven blocks, each between 20,000 and 40,000 sq. meters. The master planning has been done in such a way that each block has an inbuilt expansion potential of 20% and when the last old buildings have been demolished, the hospital will be left with an additional 60,000 sq. meters PAGE 5
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example of a modern urban pavilion hospital. Its organization is based on target groups and clinical entities, which seems natural considering the physical form of the ensemble. The urban block-based development makes it possible to build a new hospital step by step while the old hospital remains operational at all times. The dimensions of the blocks follow the grain of the grid of the surrounding city structure and are connected to each other by means of the hospital “main streets” just as a city is connected internally by streets and road networks, on second floor level with bridges crossing the city streets. All the outpatient departments are on the ground floors of each specialty block. Operation rooms and other “hot” activities are on first floor. Inpatients are housed from the 3rd floor upwards. Research labs are close to the clinical areas (mainly on the connecting second floor level) in order to facilitate communication between clinicians & scientists and students. The principal aims of St Olav’s are the provision of the optimal solution for patient-centered care and effective logistics, as well as the integration of teaching and research. The arrangement creates the possibility of achieving more clarity, more intimacy, a better sense of identity and easier way finding. A central urban space connects the hospital to the surrounding landscape and neighborhood as well as providing the access points to all the clinical centers. The hospital becomes the “medical part of town” and thus strengthens its image as part of “normality” and every day. Each “center”, i.e., each urban block, contains its own internal courtyard thus ensuring that daylight conditions remain optimal and the urban structure, in this respect also follows the traditional grain. This arrangement is an unusual contemporary solution, particularly in Europe, where even city center hospitals are usually campuses which do not follow the general pattern of a grid-plan city but usually form larger entities only loosely connected to the surrounding urban grain. One reason why this approach has worked so naturally in Trondheim might be that its 15th century urban block structure has particularly wide streets (to prevent fires spreading in the predominantly wooden environment) thus approaching the much later grid structure of North-American cities where this kind of city hospital configuration is much more common. Pavilions seem to be experiencing a renaissance. They allow greater flexibility and versatility of use but also create greater accessibility by health professionals from outside the hospital and by members of the public. This will tend to encourage a design form of linked pavilion structures with clearly articulated elements looking towards the community outside rather than deep planned monolithic blocks looking inwards to reinforce the stand-alone nature of traditional hospital institutions. The urban block-sized pavilion formula is more common in the large grid-plan cities of the United States, a good example being the Northwestern University Medical Centre in Chicago. The different “pavilions”, in spite of forming a hospital campus, can here live their own lives and have their own strong architectural character, just like the surrounding buildings in the city blocks, and they can also be replaced when deemed necessary. PAGE 6
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WHAT ARE THE KEY DRIVERS IN DESIGNING THIS HOSPITAL? Efficiency as a corporate philosophy based on outcome not process – patient focused care changes everything. • Master planning • Quality of Place • Access and Way finding • Clinical Adjacency and Functionality • Technics - ICT and Service Infrastructure • Future proofing • Sustainability The human approach builds a familiar environment ensuring safety comfort and privacy. Integration within the city an “open hospital” connected to urban life and echoing the form and scale of the city’s structures and landscape (typically 4-5 stories high). -
Sociability Receptive to cultural and social events and shared community values. Organization Operational efficiency and patient focus providing high quality medical care. Interactivity Network of diagnostic and care services throughout the health economy. Appropriateness Equip with latest technology for acute care and provide hotel standards of comfort for recovery. -
Reliability Importance on efficiency, respect for the patient and encourage human interaction and dialogue.
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Innovation Flexible and able to embrace change without impinging on the characteristics of the architectural structure.
Research Centre for clinical and scientific development. Education and training center for health education, research and professional training. Furthermore, the specialties of the hospital are characterized as “villages” and each village is grouped to form centers aligning to the particularity.
Clustering activities to create care units, possible care units:
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Mother and Child Oncology Brain and Sensory Organs Heart and Vascular Immune System, Metabolism and Aging Growth, Development and Reproduction.
Generally support units are also clustered, e.g.: Imaging Diagnostics Organ Function Investigation Pharmacy, Labs
Management Admin This
could be deconstructed/subdivided as necessary, with a large number of centers created.
Edinburgh Royal Infirmary Gastric and Liver Centre Orthopedic Centre Cardiac center Medical center Women’s center A& E department. PAGE 7
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Trondheim Hospital Norway Gynecology and pediatrics Neurological center Mobility center Abdominal center Environmental medicine center 6 inter disciplinary departments, A&E, Laboratory services, admin, supplies, training support, patient hotel.
THE HOSPITAL AND THE CITY URBAN INTEGRATION When looked at, from a point, the plan of the city blends in harmony with the hospital in the middle, that it is difficult for naked eyes to Demarcate the area. The hospital looks like a part of road network inside the city.
Going green in a Hospitals: Ecologically Sustainable Design has the following advantages
Reduced ambient air temperatures
Improved air quality
Improved water quality
Better acoustics
Improved corporate image
Improved aesthetic appeal
Reduced cooling resources through better insulation.
A NEW NEIGHBOURHOOD AND PUBLIC SPACE FOR THE CITY PAGE 8
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The hierarchy of public and private space makes the hospital legible flexible and efficient.
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LEVEL 1
LEVEL 2
LEVEL 3
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LEVEL – 1
LEVEL - 3 LEVEL – 2
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Dis-aggregation?
But Is the whole is greater than the sum of the parts? The “disaggregated” hospital is counter intuitive. St. Olav’s Hospital defies the orthodox approach to hospital design and demonstrates all of the following attributes: • Integration • Identity • Familiar Scale • Efficient • Sufficient • Adaptable • Dispensable / Replaceable • Expandable • Ordinary and Normal • Opportunities to innovate • Diversity in architecture, art and landscape. • People around the world are talking about St Olav’s – The concept is mature and innovative. • To be a world class hospital you require world class facilities to attract the best people in all areas of work. • Rest assure you that any money saved on the facilities (10%) would not have been automatically diverted to pay the running costs (90%) • Over time the quality of environment will have a significant health and cost benefit which can be measured if proper research is carried out. • St. Olav’s Hospital, Trondheim is a “landmark” in hospital design – plan.
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RESEARCH ANALYSIS:
Optimization of logistics processes in a digital hospital
More employee and patient satisfaction due to reliable service and fast product handling.
Cost and time savings due to automation of the logistic processes
Staffs relieved from continuous activities and have more time for patient care.
Reduction of potential medication errors and waste caused by out-of date medicines.
Since they can use the time and power effectively, the hospital has been converted into a teachinghospital. Students from all over the world can be enrolled in different internships and residency programs which have enabled to bring forth a forefront between education and research with patient care.
A Long List of Challenges The first challenge was to assess the requirements to conceptualize and build the university hospital. Extensive research was conducted through 500 patient and staff interviews in order to fully understand the future specifications and requirements. An extensive list of 2,500 requests was identified from this exercise.
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As a result, the research had an impact on the architecture, the urban plan, the technical platforms, the IT solutions, the staff's daily activities, and most importantly, the patients. -
The final contract, which (SLAs) that the system integrator compiled to fulfill the hospital's requests. The hospital expected impact from the ICT infrastructure to be specifically focused on:
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Mobility
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Flexibility
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Security
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Availability
With 80% of annual operational costs of the hospital being salaries, the investment in ICT in making the staff more responsive, feeling valued and being provided with leading-edge solutions is having a tremendous impact on productivity, staff retention, and improved patient care.
The Urban Link: The relationship between a hospital and the surrounding urban fabric is elaborated on in this chapter. Issues related to the other side of the coin, i.e. bringing the urban fabric into the hospital, will be brought into the discussion. This latter trend has been growing for a couple of decades. There are, however, only a few examples of hospitals where urban planning and design principles have been used consistently throughout the whole building complex. Hospital complexes are important public elements of a city. Their symbolic meaning is traditionally very strong and should not be underestimated. Along with the other traditional public complexes (town hall, church, post office, etc.) hospitals have formed the important urban network of public facilities and public spaces in cities. Hospitals were formerly built outside cities because society wanted to defend itself against those (people with contagious diseases, leprosy, venereal diseases, mental disorders or just of high age and in extreme poverty) who were put there, stored away, out of sight, so as not to disturb ordinary people. The tendency has been amazingly persistent (later explained by cheaper land, more space for logistics, parking, deliveries etc.) with the result that these “impersonal monuments” can still be found everywhere. René Gutton (1979) argues that the reverse should be the case: “A hospital, just like a city, is a network of places. It should be among the people, in the city, because it is an element of life like any other service facility. Only then will the hospital stop to be seen as a sign of forthcoming death but rather a sign of cure, of life”.
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According to Alberti, the city is no more than a great house (Alberti, 1450). Hence, a building like a hospital can be described as a small city with buildings in it. This argument extends beyond the question of complexity and scale. Above all, it addresses the issue of diversity. The Asclepieions provided sports, arts and recreation of all kinds. This is again now seen as important for therapeutic environments. The cultural and recreational values of city life are constantly emphasized. The impact of town planners on creation of an environment conducive to healing and cure in health care buildings is much greater than that of interior designers and color psychologists. The most important decisions are taken very early on in the planning process, during the programming phase. This applies to extensions of existing campuses just as much as to new complexes on empty sites. What is essential is the location of the building in the civic realm? - The selection of the site and the arrangement of the master plan to provide for well-connected and accessible networks close to transport hubs. The contribution the hospital makes towards the “making of places�, the sense of civic pride that it helps create, all form part of the recognition of the social, economic and environmental impacts that health buildings should enjoy. What are the similarities between designing a city and designing a hospital? -
Good cities and good hospitals have many things in common, but one stands out; a logical and inspiring hierarchy of streets and squares. Good hospitals have a clear hierarchy of main streets, side streets, main squares and secondary public spaces. Above all it is important to be able to articulate space; public, semi-public, semi-private and private, much in the same way as urban space is articulated. Orientation is a very important part of this. A confusing environment can never be healing. Over-specific design solutions, tailor-made plans that are created for particular moments and for particular people, are rarely sustainable and often lead to confusion and a lack of clarity.
In fact, in order to create a truly healing health care environment, we can probably learn more from good urban environments than we can from existing hospitals. The hierarchy of streets and squares, as well as public and private elements, is an important theme in many hospital projects today. This is very understandable if we consider the ongoing discourse and the complexity of the context. Together, this leads to a complicated synthesis of generality and diversity. From the 1990s onwards there has been a new kind of diversity in the urban structure. Typologies are breaking up. You can have a museum in a department store and a swimming-pool in a library.
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This presents new challenges to traditional town planning practices. Hospitals have often had courtyards that have not been actively used but simply been seen as sources of daylight in deep-framed buildings. Rarely have they been seen as assets, elements than can help to provide identity, ease orientation and so on. Internal public places have just been treated as wider parts of the corridors. In a healing hospital environment these spaces should be used to create real and memorable places that can vary according to the season or the time of day, just like urban open or covered piazzas.
One project of that period that makes a gallant effort at both reintroducing the hospital into the city and bringing the city into the hospital is the Children’s Hospital Robert Debré in Paris, designed by Pierre Riboulet, and completed in 1988. The finished building includes one of the first European “hospital streets” (Fig. 126), and manages to glue together semi-dilapidated housing areas, create a new identity to the entire neighborhood, exude
presence and power, while at the same time treat an environmentally and topologically complicated site
with admirable sensitivity.
THE WAY FORWARD: IMPROVING THE DESIGN PROCESS Part 1 — Background information -
The overall regional goals and motives. A description of the area that the plan will cover and the main activities. A short history or background information; why are we doing this plan, what has caused the need to make a plan or to revise the old plan, what is the main purpose and how do we expect the plan to be used?
Part 2 — The Activities — All clinics, departments and businesses Interviews with the various clinics, departments and other businesses ona regional and campus level recording which conditions or events that influences them the most. Discussions on what could be done to improve facilities and conditions. For example: The development in the society at large - demographic changes, clinical patterns of disease, the role of the patient in the era of the information society, the development of medical technology and diagnostic and treatment modalities. Political visions and demands from customers in a broad sense. - Demands from care providers, hospital departments and other enterprise. Part 3 — the Property -
Circumstances and conditions relating to the premises. What shall be preserved or kept up-to-date? What needs to be improved? What weaknesses can be seen? Possible alternative uses? Attached values? PAGE 16
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Aspects to consider:
The property and its current state.
Region-wide, urban or municipal plans and their effect on the development of the property.
Architecture (adaptability to urbanism or landscape, vegetation, ground conditions, cultural values, preservation rules etc.).
Basic facts for each building (size, age, technical status and categories of premises).
Communications to and within the campus (parking spaces, traffic thoroughfares, entrances, internal communication routes).
Technical and services supply systems (water, heating, ventilation, electricity, back-up, emergency, safety and security systems).
Part 4 — the analysis All the data collected and conclusions made about the available resources, activities, clinics, departments and businesses, and their needs and use of the buildings (parts 2 & 3), focusing on the entire hospital campus. The collective need for change, short (2-3 years) and long (5-10 years) perspectives. The most realistic alternatives to overall solutions studied in detail and evaluated. Pros and cons with each alternative reported, the most likely scenario chosen as the main theme for the master plan. Part 5 — the Master Plan 1. A master plan program stating the demands that the plan shall fulfill. 2. A map of the surroundings and the hospital campus describing how the area can be developed. 3. Land and building use in an overall view; structure plans and land development plans including zoning; green areas, traffic and parking, technical supply, existing buildings and areas for extensions. 4. Illustrated plans of one or several alternatives to show how the area can be developed within agreed overall structure. 5. A realization plan. 6. Phased development (minimizing disturbances), the sequence of different phases. Part 6 — Investment and maintenance plan Major maintenance needs reported and included in the financial planning for the building maintenance program. Investment plan reports costs of investments with a five-year horizon and is reassessed every year in line with the master plan. This chapter first analyses some of the reasons why the status of hospital design deteriorated so rapidly from the late 1970s onwards. Other prevalent aspects discussed here include the lack of long-term strategic planning and how this could be combated, changes in the approach to programming and briefs, as well as the incorporation of flexibility in the design development stages. PAGE 17
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The recent changes in the mechanisms that steer and control hospital design are discussed as well as the potential of process-based design as a new tool for more sustainable and future proof results. The vast majority of the world’s hospitals have been built with no long-term planning in mind. During recent decades the most common starting point has been to build a new, often Breitfuss-type hospital in the middle of an available site. The complex has subsequently been extended outwards, bit by bit. This has generally led to problems, both in the overall logistics of the hospital and in the urban environment in question. Since it has always been difficult to foresee how health care systems and consequent demands on the physical facilities will develop, there are not many examples of hospital campuses that have grown according to a preset master plan. There have been reactions to this in many countries recently. The need for master planning has been underlined by the frequent remark that “a hospital is usually outdated before it is finished”. Bringing the architects in at a much earlier stage has been seen as an advantage, and rightly so. In many countries, however, there are certain procurement practices that make this rather difficult. It has even become common to chop up the design commissions and organize a separate bidding procedure for each stage of the design process. This has led to situations where the lack of continuity in the design team has become a major obstacle in the quest for better quality and more sustainable solutions. With the ever-changing requirements, growing demands for flexibility and added emphasis on lifecycle based designs, it is evident that the traditional design processes need to be looked at critically. Although there are major variations even between the world’s developed nations in the way that these processes are handled, there are enough similarities to introduce some ingredients into the different design phases to secure better futureproofing aspects, both in new build and refurbishment projects. Flexibility should be a key issue during all the phases of the design process. The way to achieve it becomes more precisely defined the further along the process one moves. During the strategic planning phase many of the megatrends that have been mentioned in this study, such as demographic changes, developments in technology and new approaches to service delivery, come to the fore. It is important that a strategic plan is seen as a living document that can and should be adjusted at regular and sufficiently frequent intervals. It is possible that in the foreseeable future factors such as different ways to cluster services, the growing role of home care, a larger emphasis on a “core” hospital approach or a clearer separation between facilities providing “cure” and “care”, will reverse this trend. In fact, a lot of these issues were discussed in the WHO in the 1960s, which is another indication of the slowness that imbues the decision-making in the field. In the healthcare sector, there is a need for a fully thought through strategy for the future development of the resources.
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A master plan also serves as a tool for developing the real estate, the buildings and the facilities in use by the organization, and secures an efficient use of space. Above all, the master plan addresses the conditions for healthcare and its need for facilities and spaces that are adopted for the business that is conducted in them. When working on the development of master plans there needs to be a thorough understanding of the functioning of each clinic or department and the requirements of each user group. The state of the individual buildings, the infrastructure for traffic and the technical systems for heating, water, sewer and ventilation, are important factors to consider in the master plan. The master plan should contribute to the improvement of the environment for both patients and staff, thus increasing the quality of care and the value of the buildings. Master planning should provide all the essential information about the expandability and flexibility of the facility in question. It should also be seen as a living document which is continuously reviewed and updated in order to provide useful planning guidelines. Experience has shown that for most people it is difficult to think beyond a five-year horizon and to accept ideas that may dramatically change the situation that they are familiar with. This, and the fact that it is genuinely difficult to predict changes that will occur in the future makes it ever more important that flexibility is built in as a prerequisite for the expansion of facilities. Throughout the 20th century hospitals were extended and refurbished step by step. This trend has not yet been reversed and when it happens without the existence of appropriate master programs and plans, it can have disastrous effects on the long term development of the facility. Compromise
solutions, evident in almost any
major hospital campus, often have a logistic blocking-up effect vis-Ă -vis subsequent phases. They often also split up
departments, which causes dysfunctional solutions and increased operating costs. Since we cannot
predict the future, we must make sure that our actions today will not become obstacles in the long-term. The master plan should secure that the whole hospital campus is organized in a way that allows enough space for already known, as well as possible future needs. There are some recent changes in the way that hospitals are run that are going to have an effect on the master planning of hospital campuses. For example, certain support services are often carried out by off-site commercial enterprises. Presuming that this trend will continue, space provision for such services as catering, laundry and material management should allow for other functions to occupy that space if and when the strategies change. This should actually become easier in the future since major teaching hospitals will increasingly resemble small cities and development strategies will be based on entities that have a lot in common with urban zoning concepts.
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Campuses will consist of high-tech space (core hospital activities), industrial space, engineering and maintenance areas, but also facilities that can be likened to residential and commercial space. The demands from society as well as changes in the surrounding world will also influence the plan. Not only the whole hospital campus but also the adjoining city blocks and prospective plans for the immediate neighborhood must be considered in cooperation with planners from the city or municipality. Contemporary thinking, also strongly promoted in this study, sees the hospital as a natural part of the city plan, coexisting in harmony with the city, not isolated or divorced from it. Therefore all possibilities regarding the hospital campuses and its surroundings should be mapped, and needs as well as limitations recorded in the master plan. Possibilities for shared facilities with other business must also be explored. For example, a parking garage can be occupied by other users in the area and office accommodation and research facilities can be shared with the academic world or with industry. Alternative development scenarios should be studied and the consequences of all of them carefully recorded.
ARCHITECTURAL MEGATRENDS The term is here used rather broadly in order to make a distinction between primarily rectilinear and unfussy artifacts and those displaying more flamboyant, expressive features. An ever-increasing openness, flexibility and transparency are characteristics of Minimalist Modernism of the new millennium. These attributes are in no conflict with the present trends in hospital design, in fact quite to the contrary. As I have mentioned before in the scope of the study, the inside - outside is a concept that is understood by the most laymen and is welcome & there is a need for isolation, cocooning almost, in perfectly controlled conditions, but also for a healing paradise with lots of people and life around. As for creating therapeutic spatial sequences in hospitals, making sure that these boundaries perform the function they were intended for (i.e. assuring that patients, visitors, and personnel can freely use the courtyards, gardens etc.), would be much more important than some of the interior paraphernalia that is often provided for the sake of “therapeutic effect. There has hardly been a single major construction project during the 21st century in which flexibility and adaptability have not been high up on the agenda. These aspects are today more essential in hospitals than in perhaps any other building type. This study emphasizes the importance of flexible solutions in several different chapters and sections and makes references to the history of adaptable architecture. Most of the points covered earlier in this section also reinforce the relevance of future proofing and show that the prevailing architectural trends are not in conflict with the quest for better hospital architecture.
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Mobile parts in hospitals, apart from those that are directly connected to the flexibility of the spatial layout, are mainly equipment oriented. Some expensive equipment is shared by a network of hospitals and plugged into different buildings according to a certain schedule. This applies particularly to diagnostic imaging equipment but also to operating suites, etc. It is possible that with ever more sophisticated and expensive machinery, these arrangements will become more common. “In mobile solutions the need for appropriate buildings is less pronounced and, depending on the platform used,
specialized spaces may not be needed at all.
NEW CONCEPTS - Disease management and the seamless service chain
Health care systems in most countries are still today dominated by hospitals which function according to traditional and frequently inflexible
management structures. The performance level of these institutions is
evaluated through figures such as number of visits or performed procedures rather than the true effectiveness of the clinical outcomes. The need to reduce variations in practice, as well as duplication of work, has led to more emphasis being given to process orientation and networking. Quality of care is improved by monitoring both processes and outcomes. Adherence to protocols and clinical guidelines is supplemented by computerized follow-up and evaluation of the level of performance. Disease management tries, from the point of view of all stakeholders, to find an optimal balance between the quality and costs of health care.
The idea is that it will combat the present fragmentation of care, the predominance of acute care over preventive care, and the unsatisfactory results of the care of chronic illnesses. The key factors in disease management are: 1. An integrated health service system where the implementation of care and the involved parties integrate seamlessly. 2. Information systems that support the management of a disease, i.e., provide knowledge of its natural course, evidence-based management and treatment options. 3. Quality management systems based on care protocols and continuous evaluation of care results.
Care is seen as a continuous process rather than as a series of separate episodes, which traditionally has been the case. Disease management relies heavily on the exploitation of networking and data bases. This highly information-intensive concept will, through its very nature, lead to the dissolution of many artificial organizational borders and intensification of team work between different groups of care professionals.
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The concept of disease management often implies changes in job descriptions among the professional groups involved. The resistance to these changes is the main reason for the slowness of the adoption of this concept in most
European countries. A more concrete barrier that causes inertia is the separation of the management of
funding of primary care and specialized care. Many countries are now thinking of ways in which to eliminate these
organizational borders.
SETTING
FACILITY
SERVICES
Home
Health kiosk
Self-care
Cyber cafĂŠ
Monitoring
Pharmacy
Automated treatment
Home
Information and advice
Nursing homes
Health and social care centers Up to 10k population
Surgeries
Close to Drop in centers
home
Healthy living centers
Social care Primary care Outreach care Information and advice
Community care centers population Heart of the community
100k Resource centers
Day interventions
Community hospitals
Nurse led inpatient care Minor injuries Intensive rehabilitation
Chron-
ic care management
Specialist care centers 250k, 500k, Diagnostic and
Treatment & inpatient care
1000k
treatment centers
Complex diagnostic
population
Secondary care
Emergency care
On central city sites
Tertiary care
Planned interventions
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The hospitals in turn will continue to deal with specialized care but no more in a “specialized care vacuum”, but as a part of the holistic chain that
manages the patients’ wellbeing. The only thing that can be said for certain
concerning the required changes in the facilities is that the flexibility and adaptability of the buildings will be more important than ever. Short-term tailor-made solutions will not provide sustainable answers. Improved disease management leans on an improved seamless service chain, and vice versa. Modern, customeroriented service provision is generally seen as requiring the cooperation of care providers across different care levels. Clinical networks based on care pathways link the patient’s route from primary, community and specialist care and improve the quality of care. The seamless service chain also includes settings closer to people’s homes and in their actual homes. New technologies (video conferences, audio recordings etc.) can be used to minimize unnecessary journeys to health care facilities. MARU (Medical Architecture Research Unit) at the South Bank University, London, has developed a model for the Nuffield Trust which presents four settings for health care: the home, health and social care centers, community care centers and specialist care centers. All the centers are electronically networked to provide communications systems for patient records, appointments and basic diagnostic testing. The development of the home, not only as a part of the seamless service chain, but as an increasingly important setting in the provision of health care, will attract more attention from architects and other designers during the coming years. Long-term home care will include remote monitoring which provides information about the patient’s condition and also takes account of possible accidents. According to the MARU model, health and social care centers would provide a variety of services. In addition to primary health care and basic social care they would encompass information and advice activities including the availability of peer groups and various other support systems. Community care centers in turn would provide basic diagnostic services, day interventions and nurse-led inpatient care as well as intensive rehabilitation. The setting of these centers would be at the heart of local communities and they could also include mental health resource centers, day centers for older people, nursing homes and palliative care centers. In both the model, as well as in other current views, the acute care hospitals will still have the responsibility for the most highly specialized services. They will thus contain the most sophisticated technology and consequently also continue to consume the bulk of the health care resources. These specialist care centers will increasingly separate the patients into elective and emergency patient streams. Care could be divided, for example, into three elements: 1) Accidents and emergencies, with observation and assessment of emergency admissions; 2) one-stop shop consulting and diagnosis, planned interventions, day and short stay (1-3 days); 3) Complex care, diagnosis and treatment, requiring complex equipment and skills, critical inpatient care. PAGE 23
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Many of the support functions would not have to be located at the centers but could, often more efficiently, be provided off-site thus serving a number of specialist centers as well as other facilities. The specialist care centers would provide a narrower spectrum of services than the current generation of hospitals and might thus eventually become physically smaller than the postwar mega hospitals, many of which, although rarely exceeding 150,000m2 before the 1970s, have now grown to twice that size.
University hospitals perform very rare processes which require population bases of up to 5 million inhabitants in order to make economic sense. This is beginning to lead to a separation of highly specialized care which may increasingly form its own sphere within acute care. The new organization at Karolinska Hospital in Stockholm is already based on the idea that the
campus at Solana, where a new building is planned, will focus strongly
on highly specialized care and narrow specializations, whereas the 1960s complex at Huddinge will deal with the rest of the acute patient flow. Similar solutions are now being planned in many other university hospitals.
TEACHING HOSPITALS: DESIGN GUIDE In the case of university hospitals/teaching hospitals, a patient care environment along with a platform for research and teaching takes up a major part, where graduate-students are taken in for residency programs starting with a basic internship followed by specific residency courses are trained in front of practical real-life circumstances.
5 KEY HOSPITAL DESIGN GOALS
Clearing the decks for a new approach to the ideas of hospital planning begins by keeping five key goals firmly in mind:
Patient-centered care and family as part of the care process, since the patient is the hospital’s reason for being.
Efficient operations, clinical safety, optimal functional relationships, value for money, modern systems, low upkeep requirements.
Flexibility for expansion and new technology in unexpected ways over long useful life.
Sustainable design, reduced energy usage, intense 24 hr use and high occupancy.
Healing environment to include art and hospitality, not just science and technology. PAGE 24
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PLANNING FOR BUILDING SYSTEMS
Hospital circulation systems are critical not only to provide clear and intuitive way finding for families and patients, and to accommodate the many staff members and services, but also for infection control, carefully designed to separate and control public and private, clean and soiled traffic types. Planning is made more complex by the many functions which need specific adjacencies and short travel distances, while at the same time controlling and directing traffic flow. In planning the hospital, a logical and simple horizontal and vertical circulation system is the essential framework for more detailed planning. The nature of healthcare services is that relatively small rooms need to be provided for very specific functions, kept closely adjacent to related services and well apart from other functions. A typical hospital may have only a few grand spaces, but thousands of small rooms and large amounts of circulation space. The space program which guides the development of a hospital is often a document detailing the room by room space needs, planning assumptions, projected activity volume, factors for efficiency and circulation, and detailed medical equipment needs. This schedule of accommodations required is based on all of these factors, not only on guidelines in terms of space per bed. Hospital buildings also have extensive mechanical, electrical, plumbing and medical gas systems whose needs drive architectural planning as well. Each of these services needs significant space for its equipment, and benefits from the shortest and most direct distribution while keeping building services out of sight and separate from the clinical and public areas. Structural design for future hospitals emphasizes a high degree of flexibility to accommodate planning requirements that change all through the design process and interior layouts which can be expected to change many times over the years. To deal with these systems, modular planning within a consistent structural grid can be established early in the planning process to lend order to the
result. Unlike other
building types, such as schools and housing, which remain unchanged for most of their useful life, hospitals must be able to accommodate repeated waves of expansion and renovation as needs and technology change. Most hospital campuses see a series of new or renovated facilities every five or ten years, but with different services turning over at varying rates. From the beginning, the planning process must find ways to manage this need for change and to allow flexibility to meet new requirements.
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PLANNING FOR LOW UPKEEP
A major challenge worldwide is to find the right balance between simple, easily maintained materials and building systems which can be used over a long project operating life and the need for open planning which allows flexibility and change in unpredictable ways over that long term. Floor and wall materials need to be durable and easily cleaned, yet the location of partitions and doors will almost certainly change in many areas of the buildings, so the construction method needs to accept that. Even simple hospitals will now have extensive data and web-based communication and control systems, yet the components have to be easily obtained and access to them needs to be simple and clear.
FIVE TYPES OF HOSPITAL SPACE
For all of these reasons, future hospital planning starts with information from the organizer about the proposed operational plan and numbers of procedures and services, projected forward into space needs and relationships. Planning also needs to consider the very different needs of the five key components of hospital space:
Inpatient Care: The word “hospital” brings to mind an immediate image of patient bedrooms and the nurses attending them, and while this is still a critical element recent changes in technology have meant that most healthcare services are delivered in other parts of the facility. Patient rooms and nursing units have been the subject of most research into hospital design, over the last 50 years, and new data has led to “evidence-based” design which is really a shared understanding of design elements which reinforce intuitive choices: patients in bed recover faster and feel better if they can have their family with them, have more private space and amenities, and have views of nature and the outdoors. Evidence has also shown that nurses work better if given decentralized work stations near the patients, which reduces their travel, and that single patient rooms where feasible offer more flexibility for levels of care and more privacy, while reducing patient transportation and transfers. Although patient length of stay is often less than it used to be, this is still a longer term occupancy whose use is measured in days, not in hours. The architectural form of the inpatient component reflects these functional needs: compact blocks of patient rooms or wards with associated decentralized nursing support, not the long corridors of traditional hospitals, and with a high amount of building perimeter to allow maximum patient room windows. Groups of patient units can share centralized support spaces, such as conference and staff facilities, but each unit needs close by space
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for medications, clean supply and soiled disposal rooms, staff charting work stations for physicians and nonnursing staff, and adequate storage for supplies and equipment. Because the patient rooms are continuously occupied, their orientation in terms of the sun and the environment is important. New directions in patient ward design are driven as much by financing systems and cultural expectations as by medical practice. When the payment system supports more staff and more generous use of space, the current trends, and latest regulatory requirements, are moving toward larger private rooms which can be adapted from intermediate step down care to longer term care, with optimal infection control and with amenities such as private toilet and shower, entertainment and communications, and visitor accommodations. With larger private patient rooms, there is greater flexibility to meet changing equipment needs, and the long term plan is that while these units will be periodically updated and refreshed they are not appropriate to be renovated for other uses due to their specialized layout. In subsidized healthcare systems, where two-bedded rooms or larger multi-bed patient wards are still the norm, there is still an expectation that patient and family centered care and a healing environment are still important goals. Inpatient care areas are very specialized spaces, which are not easily used for other purposes, although they are often cosmetically renovated over the years of use. When the need for more beds to support the hospital’s business plan is well developed, inpatient units usually expand in increments of the bed tower, usually several floors of new nursing units, often 10 or more years after the previous project. Patient rooms need to be located with views to nature and in consideration of climate and environmental needs, and of local codes. Nursing units need to be separate from public areas, traffic restricted to staff and visitors, and no traffic through one unit to reach another. Within the unit separate visitor and staff/patient traffic needs to be considered, especially at elevators. With current trends toward new, less invasive methods of care and treatment, in most hospitals an increasing share of patient care is done on a walk-in, one day basis, rather than as an inpatient stay. Because these are short duration services and patient and family convenience is a big factor, ambulatory care functions need to be close to parking and a point of entry. Since most ambulatory care services are delivered by one or two professionals, meeting with a patient and possibly a family member, the space need is for many small encounter rooms with low technology needs which can be fairly standardized. Efficient operations and patient flow are very important, so to maximize the efficient use of space the trend is to create modular groups of rooms for examination, consulting, and treatment which can be used by different services as needed from one session to the next. Each module typically has a reception and registration work area, nearby waiting for post registration patients and their families, a block of identical exam and consulting rooms, and shared support for staff functions. A two-sided layout keeps patient traffic and staff traffic into the modules well apart and lets staffs come and go without passing through patient areas. Each exam room is carefully worked out to balance patient privacy and efficient staff work areas, with needed supplies close at hand. PAGE 27
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The layout of nursing units must provide clear and separate circulation for clean and soiled materials to support services such as food service, materials management, pharmacy and laundry. Since patient movement to and from other services is not frequent, close elevator connections are acceptable but critical care beds should be on the same level adjacent to Surgery to simplify transportation of these patients as quickly as possible. In the interest of greatest flexibility, it is generally better to locate all critical care unit types together on the same levels if possible, rather than trying to relate ICU bed types and related step down acute bed on the same levels. Inpatient units need fairly direct access to diagnostic and treatment services, efficient support services access, but should be separated from ambulatory care areas and back of house support areas.
Ambulatory Care: As the opposite of inpatient care, care for walk-in ambulatory patients is the fastest area of growth in healthcare services. New technology and new diagnostic tools have made this much more than a traditional clinic facility. Ambulatory care is now the approach of choice, with inpatient admission only as necessary for continued care or diagnostic and treatment services. While patient and family-centered care is a growing trend, unlike inpatient care the length of stay for each encounter is a matter of an hour or two, not days, so efficient use and flexibility are very important. Even with these short contacts, an orientation to nature and a healing environment improve the experience, so whenever possible exposure to natural light and ventilation can provide an inviting human-scaled space. With current trends toward new, less invasive methods of care and treatment, in most hospitals an increasing share of patient care is done on a walk-in, one day basis, rather than as an inpatient stay. Because these are short duration services and patient and family convenience is a big factor, ambulatory care functions need to be close to parking and a point of entry. Since most ambulatory care services are delivered by one or two professionals, meeting with a patient and possibly a family member, the space need is for many small encounter rooms with low technology needs which can be fairly standardized. Efficient operations and patient flow are very important, so to maximize the efficient use of space the trend is to create modular groups of rooms for examination, consulting, and treatment which can be used by different services as needed from one session to the next. Each module typically has a reception and registration work area, nearby waiting for post registration patients and their families, a block of identical exam and consulting rooms, and shared support for staff functions. A two-sided layout keeps patient traffic and staff traffic into the modules well apart and lets staff come and go without passing through patient areas. Each exam room is carefully worked out to balance patient privacy and efficient staff work areas, with needed supplies close at hand. PAGE 28
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To accommodate this modular approach to planning, large wide floor plates work better than narrow wings, so they often take the form of deep spaces with parallel front and back circulation systems to separate patient and staff traffic. Because this is a relatively fast turnover function, the ambulatory care entrance should be convenient to parking and patient arrivals and separate from other hospital public and visitor and inpatient areas. In order to get maximum efficiency in the use of this space, the current best practice is to organize services in modular units, each of which has standardized waiting, reception, exam, consultation and office areas. Each unit has patient access from one end, and private staff circulation at the other, without having to pass through patient areas. Instead of being organized as separate clinics, each the territory of one service which may use them only part time, adjacent modules can be shared to accommodate peaks of usage by overflow into the next module, while from the patient perspective there is one point of reception and one waiting area for the service. This modular layout works best with large blocks of flexible space, requiring windows at the public and staff ends but not for most exam rooms. Large programs of ambulatory care may have multiple floors or pods of similar modular space. Diagnostic services need to be accessible nearby, for referral of patients, but need not be directly adjacent. Ambulatory care needs convenient access to patient and public services, such as food services, registration, and amenities, but should be apart from in-patient areas and from back of house support. Diagnostic and Treatment Functions: In addition to the direct care of inpatients and ambulatory patients, hospitals routinely provide centralized technical services to assist in the diagnosis and treatment of patients, which need to be accessible easily to both types of patients without mixing the two. As in direct healthcare, the essence of the program requirement here is for relatively small, highly specific rooms in which specific services are performed. Diagnostic functions, to help identify the cause of a disease or condition, often include Imaging (X-ray, CT scan, MRI Scan,), Clinical Laboratory services, and Non-Invasive testing (EEG, ECG, Stress Test, Nuclear Medicine). Treatment functions may be invasive (Surgery, Endoscopy, Interventional Radiology, Biopsy, all with patient preparation and recovery areas) or non-invasive services such as physical medicine and respiratory therapy. All of these services have similar program elements- patient registration, waiting, dressing or preparation, staff work areas, office space- and a similar pattern of separate patient and staff circulation. A current planning trend to provide more flexibility and more efficiency of operations is to group related functions by type of use, cutting across departmental lines. For example, patient holding and recovery functions can be located together, with the number of staffed observation beds able to expand and contract as needed during the day, to serve a variety of functions. PAGE 29
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Flexible construction and planning for future renovation are most important in these diagnostic and treatment areas, where changing equipment needs and the frequent addition of new technology and new services require very specialized rooms to be adapted to house extremely costly equipment. The major services, such as Emergency, Surgery, Imaging and Lab are self-contained units which each have their own internal needs in terms of functional adjacency and circulation. In general, each has a public side, for ambulatory patients and their families, and patient circulation which needs to be kept separate from inpatient traffic on stretchers and staff circulation. Emergency needs a close horizontal connection to Diagnostic Imaging, and a secondary connection which is usually vertical to surgery, where patients are sometimes transferred after they have been stabilized. Imaging also needs to be accessible to ambulatory patients, but not usually with direct transfers from the ambulatory care area to imaging; this is seen more as two visits, which may or may not occur on the same day. Other interventional services such as Endoscopy and Catheterization Labs or Interventional Radiology are well located adjacent to Surgery, where they may be able to share patient preparation and recovery areas and staff facilities. Support Services: The fourth element of hospital services is the less-technical space which supports the other functions, with the ability to deal with the needs of patients, visitors, and staff members and traffic which vary over the 24 / 7 cycles of hospital operations. Support services include staff facilities such as lockers, education and training, on-call rooms for on-site medical staff, lounges and staff rooms for employees who often cannot leave their work areas for breaks, and overall administration and office activities. They also include back-of-house hotel type services such as dietary kitchens and services, materials management for clean supplies and equipment, pharmacy services, housekeeping, loading bays, waste management, and engineering and maintenance functions. Separation of circulation, for clean and soiled materials, is an important consideration, and so is efficient distribution staff time is the largest expense in the life cycle of a hospital, so inefficient distribution is a cost penalty which keeps increasing over time. Many of these support functions, unlike the spaces where medical care is delivered, utilize larger rooms and large blocks of space, but no daylight is needed for most supply and support functions. Support functions need their own direct access from an industrial loading dock, well apart from visitor and patient traffic, with good vertical connections to inpatient and diagnostic and treatment
areas. Often, staff facili-
ties such as lockers, education and training, and employee health are part of this area but with their own entrance convenient to staff parking and public transportation. PAGE 30
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Public Spaces: The fifth type of space is the cultural and emotional heart of the hospital, and the element of design which lifts it from being a technical clinical service to being a healing place. Public functions include entrance lobbies, atriums, meeting places, visitor and family accommodations, food services, amenities such as shops and public services, and access to administration and registration functions. Public access is also needed for conference centers and health information and library services. Public access, from convenient parking and pick up and drop off areas, needs to be well separated from service functions and loading areas. Visible and clearly identifiable large volume spaces are needed for major public functions, and are typically one of the slower areas to be expanded or renovated as services increase. They need to be highly visible to arriving patients and visitors and close to parking and arrivals, with the flexibility to handle large numbers of people at peak times and for special events; natural light, a relationship to the outside world, and clear way finding are all important. Directly adjacent to these public spaces are the principal ambulatory care area, access to major diagnostic services such as Imaging and noninvasive testing, and visitor access to inpatient nursing units. The public zone should be separated from major treatment functions such as emergency and surgery and from support services. MODULAR PLANNING Hospitals 50 years ago reflected the planning assumptions of the times, that narrow wings of patient rooms were desirable to allow for natural ventilation, and that once planned the hospital’s diagnostic, treatment, and support areas were relatively static. Current thinking is quite the opposite; while patient units take a form specific to their function, and are seldom modified for other functions later, the rest of the hospital needs to be easily adaptable and expandable without disruption to ongoing operations. The discipline of an overall planning module encourages these kinds of alternatives. Worldwide, the trend is toward an overall hospital planning module that can accommodate either a large ward or pairs of patient rooms, groups of typical exam rooms, one large special purpose room such as an operating room, or groups of structured parking bays. For flexibility and economy, the module needs to be part of a simple and cost-effective structural system, and one which permits later changes and modifications easily.
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APPROACH - THE FUTURE HOSPITAL: A LOGICAL PLANNING Because a hospital is by definition all about people and movement, planning has to start with circulation systems as a basic framework for any concept:
The main public entrance needs high visibility and easy access, leading to the main public space.
An outpatient entrance, also visible but separate from inpatient and visitor traffic, leads to ambulatory care clinics.
Emergency Medicine needs a separate away from public traffic, but convenient to outside access.
The service entrance and loading bays need to be easily accessible but out of public view.
Drop off and parking needs to be conveniently provided for all types of traffic.
Hospital staff parking, separate from patients, needs to be close to a 24 hour entry.
As each of these layers of circulation is added to the plan, the logical form of the hospital begins to take shape, with different types of traffic approaching from different directions and vertical circulation finding its place as logical nodes along the circulation grid.
HEALTHCARE INDUSTRY IN INDIA Introduction Hospitals are amongst the largest and most complex of all modern institutions. Hospital architecture is a part of this complexity. Unlike other organizations, which may be built in various ways, hospital building has lesser choices. It differs from other building types in the complexity of functional relationship that must exist in the various parts of a hospital. Apart from providing the right environment for patients and care providers, it should also be sensitive to the needs of the visitors including patient’s families. A number of hospitals are ideally constructed to deliver the present/ future requirements of healthcare. It is an essential requirement to examine the emerging issues, analyze the challenges, appreciate the emerging trends and study the various strategic options available for designing, planning and constructing a hospital.
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Emerging Issues The emerging issues related to hospital architecture are mainly linked to the changing role of the hospitals. The main changes that have occurred in the healthcare delivery system are as follows. Enhanced patients expectations: The patients have become more quality conscious as well as price sensitive. They expect clinical, administrative and supportive services as well as design of facilities to be contusive to their requirements.
Epidemiological and demographic changes: There has been a cascading pattern in the incidence of lifestyle diseases and geriatric related healthcare problems.
Emphasis on ambulatory / daycare: Hospital stay is gradually being programmed for high dependency impatient care and for other cases more emphasis is on shorter stay.
Enhanced standards: There have been an up gradation standards and norms in the delivery of healthcare in almost all aspects.
Changing function of hospitals: Hospitals are an evolving system. Hospitals apart from curing the sick have the added functions of maintenance and prevention of health, biomedical research and providing community outreach services. Focus has shifted from treating illness to creating wellness.
Health Insurance: Health insurance is gradually permeating as an important facet of healthcare delivery system. The providers of insurance and healthcare as well as the recipients view the hospital as an important hub for healthcare delivery.
Advancement in Medical Sciences: Advancement in medical sciences dictate/change the paradigm of healthcare delivery. Trends and dimensions in molecular biology, pharmaceuticals and surgical interventions have changed medical management outcomes.
New diagnostic and therapeutic modalities require special controlled environment, energy requirements and other engineering services.
Strategic Essentials: Hospitals inevitably are a combination of technologies, processes and human resources. Any structure may have many functions and any function may be fulfilled by alternative structure or process. Hospital architecture must facilitate technology adoption, implementation and also contribute to the efficiency and transparency of processes. It must provide a seamless integration of clinical requirements with building planning and designing issues. Strategies must be formulated to cope with differencing health needs, cultures, climates and budgets. Design responses must embrace all parts and aspects of the hospital.
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Some of the strategic issues, which must be considered, are: Design for flexibility and expandability: Due to the complexity of hospital organization and diversity in various factors such as operations, functions and development, alterations and expansion of buildings are varied and frequent. Buildings should be adaptable to changing requirements. John Weeks, the British architect had remarked. “Functions change so rapidly that designers should no longer aim for an optimum fit between building and function. The real requirement is to design a building that will inhibit change of function least and not that will fit specific function best”. Some of the futuristic patterns for obtaining flexibility are. Buildings designed to facilitate the docking of mobile and plug in modules. It is likely that specialized major diagnostic and diagnostic surgical equipment will be manufactured in self-contained pre-constructed modules intended for docking at strategic points – ‘ports’ in the building. Heat, ventilation and air conditioning (HVAC) will be modularized and zoned with vertical circulation, mechanical shafts and transport system moved form the core of the building to the perimeter in order to create free fields within the core floor plate that are easily adaptable to different layouts As and when functions/equipment expands it should be possible to extent buildings as well as equipment and installation easily. It has to be acknowledged that building and function life span differs. The golden architectural principle of indeterminacy should be followed which enables a “building to grow with order and change with calm”. In order to combat obsolescence in hospital buildings universal space modules, modular design and interchangeable components which may be reinstalled / replaced should be utilized to keep space with changing needs. Anticipate Change in Demand Functions: None of the varied elements are static for as technology develops, medical understanding progresses and their combined application expired so do social demand and expectation4. Hospitals today are focusing on sick care rather than preventing illnesses. This is likely to change in the future. Demand will change due to increase in life expectancy, health becoming a norm and healthcare focusing on prevention and intervention rather than treatment.
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The emphasis of care is also shifting from inpatient to day care. The healthcare facilities must plan for:
Daycare Facilities
Home care Facilities
Trans mural care i.e. patient tailored care provided on basis of close collaboration and joint responsibilities between hospital and home care centers Assisted living: Assisted living residences are an important concept in the continuum of care. The design should accommodate residents with a range of cognitive and physical abilities. The setting should be designed in a way that maximizes the quality of life, independence, autonomy, safety, dignity choice and privacy of residents. Healthcare hotels: These are places for convalescence and supervised care - a hybrid cross between hotel, spa and hospital. The emphasis should be more on ambulatory facilities including specialized free standing clinics, medical office buildings and specialized freestanding diagnostic centers. There may also be an increased demand for healthcare facilities on the retail model medical malls possibly in a landscaped setting 1. Emphasize on Patient focused hospitals: Patients till the recent past had become more an object on the scene than the focus of design 4. Hospitals are service organization which is essentially facilitating systems that enable users to achieve their goals in direct interaction with the providers. In a major paradigm shift, sensitivity to people’s feelings and their need for sensory input has entered the lexicon of facility planning and design. The design of healthcare setting should:
Welcome the patient’s family and friends
Value human beings over technology
Enable patients to fully participate as partners in their care.
Provide flexibility to personalize the care of each patient.
Encourage care givers to be responsive to patients.
Foster a connection to nature and beauty. The objective is to create a patient focused, patient centered architecture by offering an atmosphere of safety, security, cleanliness and physical comfort. PAGE 35
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Focus on Energy conservation: Emergency conservation must be planned and implemented some of the measures are:
Use of high efficiency light sources.
Natural light utilization.
Effective ventilation.
Easy maintainability.
Energy recycling. Create a Healing Architecture: A hospital needs to be the most wonderful place in the world. It needs to heal. The hospital must have a humanizing architecture that can positively contribute to the healing process. Studies have linked poor healthcare facility design to elevated blood pressure, anxiety and longer hospital stays following surgery6. The physical environments of the hospital should fulfill the following two conditions:-
It should do no harm
It should facilitate the healing process Exposure to nature through interaction or access to view has a positive healing effect. Hospitals should provide a cheerful and inviting ambience and a caring and healing environment. Life enhancing designs are architecture that facilitates:
High quality of care and access in a setting that is supportive of human relationship during times of great anxiety and fear.
“Our stop shopping” that caters to the diagnostic and therapeutic needs.
Facilitates ease of maintenance.
Provides patients sense of safety
Provision of pleasant space for patient’s families and friends.
Natural light.
Facilitates care.
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Aesthetics – An Essential Requisite: Though patients give the highest priority to obtaining the best treatment, it has to be considered that they are people with eyes, ears and other senses and deserve to receive pleasure from the environment.
Aesthetics is now considered an essential ingredient of hospital design and planning. Aesthetics, which is the quality of the total experience our surroundings give us as, perceived by our senses and intellect, should be planned for all its dimensions as follows.
Psychological aesthetics which includes happiness, joy and pleasure.
Spiritual aesthetics, which suggests hope, contentment and peace
Physical aesthetics implies wellbeing, ease and convenience
Intellectual aesthetics inspires humor, interest and contemplative delight.
Go for Green Hospitals: The emphasis of healthcare architecture must be on improving the quality of the environment for patients and health care providers. The hospitals should be environment friendly. Some of the parameters which may be considered are:
Designed to make best use of passive solar energy.
Utilization of renewable sources of energy such as solar, wind and biogas
Proper waste disposal
Go organize.
Use materials utilized in hospital building should be noon toxic and non-allergic
Use of natural light by construction of a truism
Ventilators. Visualize the Hospital of the Future: In the future that more common hospital functions will move close to patients and only a few specific specialized functions will be concentrated at other places. The concentration of specialized facilities and dispersal of other hospital function will influence the building design and planning as well as facilities to support the continually changing hospital functions. A number of smaller facilities will be required at several locations to accommodate the dispersed functions and larger facilities at an early accessible location to accommodate the concentrated functions. When the amount of intervention becomes higher or the impact of the intervention becomes lower, request for dispersion function grows.
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Since function will be continually be transferred to the decentralized health facilities as new function are introduced in the specialized centers, flexibility and expandability in the building design at both centers in a necessity. The vertical differentiation of hospital care leading to the specialist oriented building archetype was suitable in cases in which patients are treated by specialists very individually. With the increasing specialization and advances of medical technology hospitals are being designed around distinctly different function. The different hospital function may be accommodated in different buildings. These may be diagnostic buildings, a building for pre-clinical services, a building for daycare including surgery, a building for special medical treatment and intensive care, a logistic center, an office building and an education / scientific building. The hospitals of the future will have architecture plan and design facilitating continuous improvements in healthcare, improved technologies ominous convergence of the clinical, administrative of diagnostics and therapeutics. There will be hard and hospitality dimensions of healthcare delivery. The hospital of the future will successfully be reformed into organ based centers that have a building of their own. The patients would only be moved around in the hospital in exceptional cases of when there is a need for highly specialized diagnostic equipment or treatment. In the specific buildings for such a center there will be beds and equipment as well as possibilities for diagnostics, treatmentlized radiology and so forth will be able to link up with smaller hospitals and local care centers. The centers will through the aid of telemedicine, digital the future will not just be a hospital as a decentralized network, serving petite recognize it today, it will be hub intent not only in the hospital but also in local hospitals and their homes.
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RAISING THE STATUS OF HOSPITAL DESIGN Architecture is, by its nature, a multidisciplinary endeavor. This is the case in any building design task, however humble. In certain building types, like hospitals, the puzzle that an architect has to decipher is somewhat more complicated than in most other building types. The portion of the creative ingredient that encompasses artistic, aesthetic and visual matters is nonetheless so overriding that architecture can never be seen as pure science, something that can be evaluated in absolute terms. Thus there is no empirical way of proving that one piece of architecture is better than another. The evidence has to come from the professionals: the critics and the theorists who have the educational and practical background required to evaluate the aesthetic as well as the functional and technical quality of buildings. Through modernity, architects have always been primarily evaluated by their peers. The evidence base that has been used to rank architects is founded on the number of successes in major design competitions and the extent to which their buildings have been published in respected professional journals. It is unfortunate that many architects currently working on major health care projects around the world do not figure in this evidence base. In order for hospital buildings to be sustainable symbols of civilized health care, they have to be manifestations of the best architecture that a particular era can offer. Our aim should be a significant increase in buildings of the highest architectural quality that serve health care in the coming decades. Instead, we continue producing edifices that both the professional critics and the general public look upon as necessary evils, buildings that, apart from being functionally deficient and short-lived, are not even intended to contain any meaningful messages or poetic attributes. Too little has been learnt from past mistakes and too little gained from successes. A WAY FORWARD FOR FUTURE HOSPITAL DESIGN In developing these ideas, it was very important that this new concept should not be a recycled North American or European hospital plan type, but should focus on the basic ideas which need to drive hospital planning worldwide. The result is not a fixed design, but is an approach to planning which can be applied at different sites and in different sizes. What is most important is to focus on a planning process leading to form, not on designing an architectural idea first. It was also critical to think in terms of an open system of planning, in which variables such as required services, anticipated volume, operational and staffing assumptions, and building system decisions could all be adjusted PAGE 39
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and tuned as needed while keeping in mind the basic goal of a high quality, low upkeep, flexible and expandable hospital concept which can be an expression of a new hospital type for world use. If the quality of our future hospital buildings is to be significantly improved and the challenges involved successfully tackled, the status of health care design commissions among architects has to improve drastically. The best medicine for this would be a permanent flow of high quality contemporary precedents appearing in the professional journals. Few recent hospital designs have made a positive contribution to mainstream architecture and it is thus hardly surprising that contemporary architectural criticism seems to ignore the field. Healthcare building design is not perceived as fashionable, either in most practices or in the architecture schools. Schools of architecture have generally not been active promoters of the appeal of hospital design, although the traditions are old. Essential as it is to make the field attractive to undergraduate architectural students in order to promote the status of the field, the single aspect that contributes to the lack of change is the procurement process. It is this that in many countries has contributed to the general demise. Hospital commissions are given based on a low price and a past track record in health care design. This leads to continuing stagnation and a lack of new ideas. Current procurement methods have led to only very large organizations having a chance of getting involved. The result is depressing because most of the time good architects are successfully kept out of the picture and the low esteem of the field continues. Open architectural design competitions have traditionally been an effective way of improving standards, identifying talented new designers and procuring design services from occasionally unpredictable sources. However, there have been relatively few open competitions for healthcare buildings as compared to those for other public amenities. The argument has been that open competitions are wasteful since previous experience is in any case a prerequisite for producing a valid entry that could be implemented. On the other hand, there have been occasions when the organizers have had the foresight to make lack of experience an issue and insisted that new names would be given a chance. Every competition that is organized helps to improve the status of health care architecture, particularly if the results are well disseminated. Competitions in which the participants are given more leeway to take part in the conceptual thinking behind the physical framework are even more valuable.
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The remedy for the improvement of the status of hospital design is simple. We need better buildings. Better buildings will get published in the journals and gradually better books will also start appearing. In order to get better buildings we need more intelligent methods for the procurement of design services as well as adequate fees. The lowest fee should never be a decisive procurement criterion. Timetables and fee structures should allow for innovation, not just repetition of what has been done before. More time and consequently more money should be given for the design process. The importance of previous references in the field should be played down since health buildings are clearly becoming more generic in character and since the present system makes it very difficult for the best architects to enter the field. The same design team should be involved in the design process from the beginning to the end. The present trend to chop up commissions and appoint different architects for different phases of the design process, presumably in order to save money and keep stricter control on the process, is shortsighted and illogical. As an active designer and researcher in the field of health care architecture, it is encouraging to be surrounded by care professionals and administrators who are enthusiastic, knowledgeable and open to new ideas. It seems that the number of these people is on the increase everywhere. They follow the relevant international discourse, they take part in conferences and seminars, visit projects in progress as well as new realizations, and are much more aware of the need for better architecture and design than their predecessors. MODERN CONCEPTS: THE 2004 CONCEPT (Cure for Sure): The brief stressed the fact that, apart from being functional and patient-focused, the hospital of the future is also the premises of an enterprise. This would bring into focus certain aspects such as an increased awareness of quality among the users of the services, innovative strength in all activities and especially the need for a more competitive physical setting. Optimal functionality was seen as a vital prerequisite for the enterprising and competitive hospital. In consequence, the facilities had to be designed in such a way that all possible new forms of care could be accommodated with minimal disruption. This naturally led to a demand for a very high level of future-proofing. Efficient and logical patient flows as well as the general spatial and functional organization of the hospital were to be based on the presumption that the care would be modelled on the patient’s anticipated care program (both within and outside the hospital), i.e. the principle of care pathways. THE 2007 CONCEPT: (Fair Care- Care Fair): According to the assignment, the healthcare for this city had to be developed in its entirety. The city would require all the basic facilities, so that the residents would only need to go elsewhere to acquire the very highest level of specialist medical care. The assignment was to develop ide-
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as for the layout of the healthcare sector in this new city in 2025. The ideas had to be translated into an organizational and spatial design of the healthcare facilities, and an elaboration of a portion thereof. The full spectrum of the healthcare sector (“from maternity care to terminal care, from home help to intensive 24-hour care for mentally disabled, from simple outpatient treatments to heart surgery”) was included. Put succinctly, the task was to design a city, to plan a healthcare system to serve it and to design the buildings to serve that system to promote interdisciplinary and unconventional thinking at the interface between healthcare, policy, entrepreneurship, town and country planning and technology. The brief emphasized a considerable number of the issues that have emerged earlier in this study. The changing demographic patterns were taken up as a major influence on the character and quality of the facilities that will be required during the coming decades. The new breed of health facilities will be based on a new kind of distribution of the various traditional elements because of an increased consideration for the smoothness of care pathways. Healthcare will also be more tailored towards chronic disorders. Parallel with demands for organizational upscaling, generally seen as economically unavoidable, there is an increasingly outspoken patient-client body that is calling for smaller-scale solutions closer to home. CONCLUSION: A number of existing hospitals do not have the architecture to effectively deliver patient care. They were mainly designed when patients were considered more an object on the scene rather than focus of design and thus were death rioted from the hospital architectural planning. Hospital architecture must focus on improving the quality of environment for the consumers and the care givers. Hospitals must be designed to support the processes that have to take place within the building to treat the patients in an efficient manner. The hospital building must evoke positive responses. State of the art technology and human sentiment can be adopted, adapted and implemented to create an unrivaled architecture. The nature of a hospital building determines to a certain extent the effectiveness of healthcare and other processes that take place. W. Churchill had said “First we shape our buildings, thereafter they shape us”. This is certainly true of the hospital building. Architects and hospital planners have to keep pace with the advancement in modern medicine, nursing techniques and community clientele expectation. The above report on “healthcare architecture” argues that the main problem with the great majority of the hospitals in the world has been the lack of sufficient architectural quality. The hospital, which should be one of our most significant public buildings, has far too often been thrown out of the city and designed by “specialist” hospital architects using briefs based on “for me, just now” principles. Instead they should be built in city centers, using future-proof programming and the best possible architects, preferably commissioned through open architectural competitions. PAGE 42
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REFERENCES: Hennu Kjisik: THE POWER OF ARCHITECTURE Towards better hospital buildings Planning Hospitals of the Future: Richard Sprow, AIA. Netherlands Board for Hospital Facilities (College Bouw. (2002). the general hospital: Building guidelines for new buildings). Thiadens, L., et al. (2007). EuHPN (European Health Property Network)
Network Study: St. Olav’s
Hospital. Ulrich, R. (2006). Evidence based healthcare design. In Waggener, C. (Ed.), the architecture of hospitals. Neil’s Torp, Medplan, Frisk Architects et.al.,(1996-2015) Zumthor, P. (2005). Thinking architecture. Basel: Birkhäuser.
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