Healing Hospital_Mater Thesis LSAP

H HEALING HOSPITAL Upycling the OLD for a healthier NOW

H

Master Thesis Report by MarĂ­a Soledad LarraĂ­n Salinas

HEALING HOSPITAL Upcycling the OLD for a healthier NOW

Master Thesis Project by María Soledad Larraín Salinas Healing Hospital: Upcycling the old for a healthier now.

Examiner: Michael Eden Professor: Walter Unterrainer External Supervisors: Juri Soolep -Peter Kjaer.

Umeå Universitet _ UMA School of Architecture LSAP Laboratory for Sustainable Architectural Production Master Program 2010-2012

4

H Thanks to...

My family for all the support during this time apart and encouraging me to take risks, travel and believe in my projects, specially when that meant to be away so far and for so long.

Alice Lindstrรถm for her guidance through the very complex subject of health care and believing in my proposal and the relevance of its outcome. And with her to all the staff of Malmรถ University Hospital and Regionservice Malmรถ for letting me invade their premises and for their valuable time answering my questions and showing everything, but above all their tremendous disposition to help me.

To my teachers for their advice on assuming this subject and allowing me to see it through.

To my classmates for opening my world to so many cultures, and giving me the chance to experience so many different languages, food and places, and above all for making me want to go to all those places afterwards and visit.

To my swedish friends for teaching me so many lessons and letting me share incredible moments and traditions. Specially to Johannes for being my little angel watching over me when I needed it the most.

To my chilean friends in Sweden, for their unconditional presence and being my family away from home.

To UMA School of Architecture for establishing a great space to create and propose, and letting me be part of it.

And to everyone that was part of this great experience.

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CONTENT

6

PART 1 : RESEARCH THESIS STATEMENT 8 MOTIVATION 10 HEALTHCARE 12

Health: What is and How to Achieve it?

14

Healthcare Through Time 18 The Hospital Now 24

THE HEALING ENVIRONMENT 28 What to Take into Account 30 Factors and Effects 34 Evidence Based Design 42

PART 2 : MALMO UNIVERSITY HOSPITAL HISTORY AND CONTEXT 46 VISION 48 ANALYSIS AND MAPPING 50 STRATEGY AND MASTERPLAN 54 BUILDING 65 Existing Building 56 Existing Room 62 NEW BUILDING 65 Strategies to Upcycle the Structure 66 New Ward 80 New Room 84 CONCLUSIONS 96 REFERENCES 98

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The healthcare system founds itself ill from the fact “­that it has no philosophers in its midst. That means it thinks too little about basic things, such as: what is happiness, actually?”

Shmid, Wilhelm. In: Brink, Nana: Erste Hilf Die Zukunft der Krakenhäuser. Deutchlandra Kulture, 12 February 2005.

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THESIS STATEMENT

In the world today cities are getting overwhelmed to keep up with the demographic explosion, not only they have to grow, but densify; not only to provide infrastructure, but to update it.

One of the most high impact areas is health care, which gives an opportunity to intervene in a never ending process, since a Hospital is never finished and it is a continuous building site, making the health sector be always in need of re-using, re-cycling and new proposals.

Skåne University Hospital (SUS) in Malmö is responsible not only for the city but for the whole region. In combination with Lund’s University Hospital with a recent addition, they are responsible of taking care of more than 1.5 million people in southern Sweden. Nowadays, SUS Malmö is situated in a complex urban plot, with invisible layers and links. In the same spirit as the region council, who’s the one running the projections and development of the institution, the hospital has to improve its services, increase its surface and beds, and upgrade its quality, not only technical but spatial and functional.

The re-use of its current infrastructure is required, but an assessment is needed to see what can comply with the new requirements for what the call “the future wards” which are to be thought over, introducing a new health concept. The role of the hospital, and the experience of being in one are changing and Malmö Hospital has to stay updated and take action towards the new techniques and demands.

The challenge is to create a new ward within the existing structure, in the heart of the hospital. Proposing its communication system and how it would insert itself in the dynamic system, focusing in: clear circulation for patients and visitors, efficient flows for staff and equipment, and fast delivery of results and information. The aim of this proposal is to create and efficient system while focusing on the healing environment in the different spheres: patients, visitors and staff, making the hospital a healthier place to be.

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WHAT? RE_USE

WHERE?

HOSPITAL

WHY? IMPACT

HOW?

UPCYCLE

WHO?

COLLABORATION

10

MOTIVATION

The urban migration is expanding cities in an extreme way, to avoid these we have to re conquer and re use our cities and find a new way to inhabit them.

We have to start recycling more than plastic. Our attitude toward re using has to go further than a fashionable thing, to a social strategy. The aim is to implement this attitude into one of the most important social engines of the city, where great impact can be achieved: the hospital.

By getting involved and assuming a propositional attitude, the idea is to demonstrate that not only we can re use resources but also you can create better realities, by rethinking health and what is being healthy.

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H What is health?

The World Health Organisation (WHO) defined health in 1948 as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.1 This coincides closely with the holistic view seeing the patient first as a person within their family, community and workplace, and recognising the positive and negative influences each can have on the person. Helping an ill person back to better health requires due account to be taken of factors other than their physiology and anatomy; meeting psychological, social, spiritual and environmental needs are important.

1 World Health Organization. 2006. Constitution of the World Health Organization - Basic Documents, Forty-fifth edition, Supplement, October 2006.

HEALTHCARE Upcycling the OLD for a healthier NOW

HEALTHCARE:

What it is and How to achieve it.

If we take the matter in a simple way, hospitals are the institutions that implement society’s health care, but we start with a void: what is health care? Who are we caring for? And what should they care about?

When people is asked about the role of a hospital, in the majority of cases the concept: take care of the sick, comes up.

But when asked what is health and being healthy, more choices come to mind. Health as a more general understanding is not

Sjuk hus = Building of the sick, comes from the middle High German siecen-hûs, which was designated a hospital for lepers.

just a state, but also “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”1

(New Hospital Buildings in Ger-

As the early word comes from a less medical root, hospital per se comes from the sense of hosting, where there are two

many, page 12)

actors in a dynamic relation: the host and the guest, each havthe

ing its role. The concept of hospitality is born as offering comfort

ospital

and guidance to strangers, which during time has been lost in

“hostel” (Mod.Fr. hôpital), from L.L.

the hospital duty and responsibility. Is here where information,

hospitale “guest-house, inn,” neuter of

but specially trust come into place, two concepts that are natu-

Latin adjective hospitalis “of a guest or

rally there but should be implemented and strengthened. As

host,” from hospes (gen. hospitis); see

was mentioned health is a double relationship, where we get

host (1). Later “charitable institution to

cared for when in sickness, but there is much more to do before.

house and maintain the needy” (early

Our health is bounded to external factors such as genetic and

15c.); sense of “institution for sick

environmental agents. From our transport system to our politic

mid-13c., needy,”

from

O.Fr.

“shelter hospital,

for

people” is first recorded 1540s.

1 World Health Organization. 1986. Ottawa Charter for Health Promotion, http://www.etymonline.com/ index.php?term=hospital

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adopted at the First International Conference on Health Promotion, Ottawa, 21 November 1986 - WHO/HPR/HEP/95.1.

AC COMM C UN IT Y INDIVIDU A BIO-GE

SO CI O -E

SICKNESS

+

HEALTH

ELEVATED LEVEL OF WELLBEING AND PERFORMANCE CAPACITY

WELLBEING

NS IO IT

-

HEALTH

T S POR SU L IA STYLE FE LI ORS CT

PREMATURE AND PREVENTABLE SICKNESS AND DEATH

URAL, ENVIRONM EN ULT TA ,C C I L ORKING CO M CO W D O ND N AN N IT G D O IO N C I N LTH CARE A V E S S H E LI RV TO IC S CES AND E ES UEN L S F O C IN CTORS AN D FA L TIC FA NE

strategies and agricultural legislation, all actions impact on the final personal health.

Actually today some of the diseases that are affecting a majority of the populations and collapsing our health system come from unhealthy and uninformed behavioural choices in a daily basis. According to WHO (World Health Organization) in their 2009 Report, “Global health risks: mortality and burden of disease attributable to selected major risks”, the risk factors on high-income countries are directly linked to non intelligent choice of life style and lack of health education, such as: tobacco use and high blood pressure, more than to environmental

20% 19%

factors, such as water pollution and sanitation infrastructure.

10%

As a matter of fact the most important factor that will determine our health is life style. Over a 50% of our health condition will be guided by our life choices in matters like: eating, exercising, sleeping, smoking and relaxing2. Many of this items are not seen as very influential in ones life, but more and more

51%

is been proven that on a medium/long term, simple things like exercising constantly will have a bigger impact in someone’s future condition than treating the resulting disease afterwards.

Though many factors seem further than our personal range, it’s important to realize how health is a joint cause and every actor involved has it own role to play, from local government to social institutions. Health as we know is not just about not being sick, but a whole range of other aspects, that is why today health care is not seen just like a hospital, but a dynamic network, wived into the urban fabric. The hospital till now appeared as the safety net of the system, when nothing else worked, but latest trends involve the hospital’s mission with broader issues than just treatment.

In a broad look there is a clear process that guides healthcare, and will in an end point guide the planning of a hospital. We can identify five very distinct stages where society, or in this case the patient, move through. Its important to understand that though the different stages are always present in 2 McGinnis, J. M. and Foege, W.H. (1993). “Actual Causes of Death in the United States,” Journal of the American Medical Association, Volume 270, Number 18: 2207-2212

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PREVENTION

DETECTION

DIAGNOSE

TREATMENT

END OF LIFE

Five main processes in healthcare:a citizen perspective; Bo Bergman, Duncan Neuhauser, Lloyd Provost. Downloaded from qualitysafety.bmj.com on February 28, 2012 - Published by group.bmj.com

the health care system, some times the focus is invested in some of them instead than over the whole cycle.

Prevent: This is the stepping stone of the system, cause this sometimes simple action translates in further benefits for the whole system. Simple actions like: physical fitness, bed nets against malaria, a good diet, clean drinking water, less use of tobacco, etc. Preventive action is taken sometimes as a quite personal matter, but for it to have a real impact in the overall system is necessary that is reinforced with social initiatives, such as proactive prevention of future illness. The whole point is in the line of a popular saying: “there is no better patient than the one that is not sick”.

Detect: Nowadays the healthcare system helps who comes with a condition, and sometimes in that situation is already late, that is why proactive outreach on the part of the healthcare system is important. Monitoring and detecting conditions in early times is not only efficient for the system, but also beneficial for the patient. This strategy must be impulsed by the health institutions and also governmental campaigns, focusing and spotting behavioural and medical trends in the community, so they can be addressed before a condition becomes a disease.

Diagnose: This is probably today’s one of the key processes in a hospital performance.

An on time and efficient diagnose is probably one of the most cost effective steps, where health management can improve their performance. For the organization is a way to save resources and time, which translates in the possibility of relocating those resources where they are really needed. A miss diagnose can waste a lot of time and human workforce, but the most relevant is also that the timeline of a diagnosis is critical for many disease paths.

Treat: This is the core of health care’s mission today and through time, though this is a very technical and specific process, it is the reason for why people resort to the health system.

Though curing is important, caring has become a side concept, expanding the technical treatment to a more complete view of recovery.

End life: Probably one of the most controversial stages in healthcare, has to do with giving life quality to whom is about to die. In difference as the other processes, this does not require of specialist of different areas, but a more holistic approach that give relief and a good end period of life for people in that path. Is not about effective endless treatment trying to fix something broken, but to reflect on the general state of the patient and what is better for their case. For example there is no point to do a high risk operation to fix one organ on an old patient who’s entire system is shutting down, but to improve its environment.

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THE DETERMINANTS OF HEALTH

Many factors combine together to affect the health of individuals and communities.

Whether people are healthy or not, is determined by their circumstances and environment.

To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. The determinants of health include: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviours.

The context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the above factors, and many others: Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.

Education – low education levels are linked with poor health, more stress and lower self-confidence.

Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health.

Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health.

Genetics - inheritance plays a part in determining life span, healthiness and the likelihood of developing certain illnesses.

Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.

Health services - access and use of services that prevent and treat disease influences health Gender - Men and women suffer from different types of diseases at different ages.

World Health Organization _ Health Impact Assesment http://www.who.int

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HEALTHCARE THROUGH TIME: The Hospital Journey.

Hospitals have come a long way through history, not only in a formal point of view, but most important in their genesis. They have been a kind of reflection on society all along, because the definition of health and health care goes deeply rooted to what is the concept of person and society. To understand where is the debate now, and why has it got here, we need first to understand the journey of this institution, that through the centuries has been evolving looking for the right way.

Some of the earliest documented institutions aiming to provide cures were ancient Egyptian and Greek temples.

In ancient Greece, they were dedicated to the healer-god Asclepius, known as Asclepieia. This temples presented themselves as centres of medical advice, prognosis, and healing1. At these shrines, patients would enter a dream1 Risse, G.B. Mending bodies, saving souls: a his-

Temple of Asclepios, Greece -600

18

Valetudinarium Hospital, Rome -100

200

100

0

Academy

Military Hospital

_Antidote to poison

200

Temple of Asclepios, Rome -293

100

Temple

Medirigiriya Hospital, Sri Lanka -400

300

Bath 400

500

600

Nature

Human

Technology

Temple

_Athens Plague

tory of hospitals. Oxford University Press, 1990. p. 56

Gundishapur’s Academy, Pers 271

sia

like state of induced sleep, in which they either received

well-organized hospitals, staffed by doctors who were both

guidance from the deity in a dream or were cured by sur-

male and female. Facilities included systematic treatment

gery. The worship of this god and the treatment rituals

procedures and specialized wards for various diseases. The

were kept by the Romans.

Christian tradition emphasized the close relationship of the

After Romans converted to Christianity, health cov-

sufferer to his fellow man, upon whom rested the obliga-

erage expanded through the empire. Following First Coun-

tion for care. Illness thus became a matter for the Christian

cil of Nicaea in 325 A.D. construction of a hospital in every

church.3

cathedral town was begun. Among the earliest were those

Medieval hospitals in Europe followed a similar pat-

built by the physician Saint Sampson in Constantinople and

tern. They were religious communities, with care provided

by Basil, bishop of Caesarea in modern-day Turkey. Called

by monks and nuns. Some were attached to monasteries;

the “Basilias”, the latter resembled a city and included hous-

others were independent and had their own endowments,

ing for doctors and nurses and separate buildings for vari-

usually of property, which provided income for their sup-

ous classes of patients, with a separate section for lepers.2

port. Some hospitals were multi-functional while others

Some hospitals maintained libraries and training programs,

were founded for specific purposes such as leper hospitals,

and doctors compiled their medical and pharmacological

or as refuges for the poor, or for pilgrims: not all cared for

studies in manuscripts. Thus in-patient medical care in the

the sick.

sense of what we today consider a hospital, was an inven-

In Europe the medieval concept of Christian care

tion driven by Christian mercy and Byzantine innovation.

evolved during the sixteenth and seventeenth centuries

Byzantine hospital staff included the Chief Physician (ar-

into a secular one. It was in the eighteenth century that

chiatroi), professional nurses (hypourgoi) and the orderlies

the modern hospital began to appear, serving only medical

(hyperetai). It can be said, however, that the modern con-

needs and staffed with physicians and surgeons. The bour-

cept of a hospital dates from AD 331 when Constantine ,

geoisie started founding the new hospitals in the fast grow-

having been converted to Christianity , abolished all pagan

ing cities. Now they were civic buildings, commissioned by

hospitals and thus created the opportunity for a new start.

authorities , but usually managed by religious orders. Hos-

Until that time disease had isolated the sufferer from the

pital became the face of reason, of progress. Though the

community. By the twelfth century, Constantinople had two

world was still runned by aristocracy and the church, the

2 Catholic Encyclopedia - [1] (2009) Accessed April

Saint Basil the Great, Cappadocia 369

Xenodochium of Mérida, Spain 580

Abbey of Saint Gall, Switzerland 612

Hôtel-Dieu, of Paris, France 651

_Black Death Plague

1300

Church

1200

Crusades

1100

_Lepers are isolated from society

Church

1000

900

Charity

Infirmaries 800

Convent 700

Inn

200 600

_Plague of Justinian

500

400

100

300

3 http://www.edwardtbabinski.us/history/hospital_ history.html

Monastery

2011.

Santo Spirito in Saxia, Italy 1204

19

hospital became an island for the rational thinking and a symbol of what was coming after, started by the french revolution in 1789.

A stepping stone was in 1772 when a big fire burned the Hotel Dieu in Paris, in icon of healthcare of the times.

After this event, there was an opportunity to re-think and propose new environments for the sick. Even though nothing was built right away, it fuelled the discussion, shifting the healthcare aims of the time. Now it wasn’t a place where to accommodate poor and sick people, but to take care of the “common man”. By 1859 Florence Nightingale, an Italian nurse with high knowledge on health statistics, noticed that the death rate in city hospitals was much higher than the patients in a same state treated outside this institutions. This became a turning point on the objectives of hospitals of those days. The urbanity of the time was faced with a mayor issue: hygiene, and hospitals turned in search of clean air. This quest became the first step towards natural environment, and relating nature to the healing process.

Though the popularity of the pavilion type grew, the importance of nature took a step to the side and medical advances took over. Now the pavilion model was a representation of medical specialization, a series of small hospitals inside the original one.

Everything changes by 1895, when Röntgen, a German physicist discovered and shared the X-Rays. Now health care was not so much about the care, but instead,

Hospital San Pau, Barcelona Guillem d'Abriell 1401

20

Hospital of Jesús Nazareno, Mexico Pedro Vázques 1421

Hospital leeuwenberghkerk, The Netherlands 1567

Royal Hospital Chelsea, UK Sir Christopher Wren 1681

Academy

1700

Military Hospital

_Bubonic Plague

1600

Voluntary Charity

1500

Secular Institutions

_Colombus discovers America

1400

Guest House

_Black Death Plague

technology took its place. With this turnaround now hos-

Hospital Charite, Berlin 1710

Ho J. 17

pitals became full of new equipment, and with that the

of sciences, as to become in effect a scientific instrument

services provided became out of reach for the poorest and

not essentially different from the X-ray machine or the op-

needy, which till now was its objective crowd. Hospitals

erating table which it encloses. It is hard for people to

came from almshouses to top medical institutions, chang-

imagine any relationship between such a building and that

ing the aim from helping the ones in need to developing

great tradition whose flowers are the Parthenon and the

technology. The pavilion system showed to be inefficient

Cathedral of Chartres. It is hard to think of a hospital as a

with the long distances and communication issues, and the

work of art”

expensive machinery forced to go back to concentration of resources. Now doctors, machines and the elite where

J. Hudnut, ‘Architecture and the Art of Medicine’, in Journal of the

the inhabitants of the new hospital: the Block Hospital.

American Institute of Architects, 1947, n°4, 147.

Highly concentrated and big scale representative building conquered the city. This monumental creature lost the

After the Second World War, and due to the social

feature and ambition to create healing environments that

revolution that came with it, the “welfare state” concept,

would emulate nature. This machine like buildings accom-

shook things for hospitals again. The late examples of

modated technology and resources in a efficient and cost

technological sanctuaries had to open way back to the “

effective way. Nature and small scale movement became

common man” and safeguard its health. The hospital re-

an artistic ideal.

gained its role as a social institution, and became a monu-

This shift lead to over organized, technology ridden, anti-human establishment, mostly blamed to the modern-

ment for welfare, and entering a new age of science progress as social justice.

ist architecture. Though during the 20’s and 30’s avant-

This new capitalistic oriented welfare found its face

garde modern movement shared the nature-oriented view

in the international style, which introduces back the refer-

of the beginning of the century, but didn’t got the chance

ence to nature, taking this urban institution to the outsides

of taking those ideals to reality.

of cities in the search of spacious locations. The architecture became synthetic, a combination of three parts and

“No art is more widely misunderstood than the art

characters: Patient ward, Medical Treatment, Daycare.

of architecture, and no building illustrates the misunder-

This became a grouping exercise and a typology test for

standing more clearly than the hospital. The hospital has

architects, resulting in during the 50’ and 60’ in several

become completely a product of the technologies of medi-

types named after the letter they resembled: T, K, L, H.

otel Dieu, Paris .B. Leroy 773

Vienna General Hospital, Austria 1784

Selimiye Barracks, Turkey Florence Nightingale 1854

Lariboisière Hospital, Paris Pierre Gauthier 1854

St Thomas Hospital, London, UK H. Currey 1865

1900

Specialisation

During this time medical technology and science

Pavillion Hospital

Statistics

200

1800

_French Revolution

100

Inn

Urban Hospitals

_Hotel Dieu burns down

cine and of manufacture, so precisely adapted to the uses

21

where moving faster than the have ever done it before, and it was precisely this that became the biggest challenge for architects and hospitals. Adaptability became an essential design aspect to keep up with the dynamic scene of technology. As a result of building experience during 50’s and 60’ American Military Hospitals came with a strategy for this changes. Most of the technological changes would occur in the treatment and outpatients area, so for this they would have a low horizontal building, easier to retrofit and redesign, and the patient wards that was the area with less change could be concentrated in a high rise building.

This was a building boom for hospitals, especially in Europe and the United States, where this new slick and high tech building took place, again an example of rationality, but this time was seen in another way.

A counter culture, instead defined it as a bureaucratic creature that represented the political and economical establishment. The hospital became a bureaucratic sphere, governed by politics or big companies, and this influenced the inner life of it. Patients were not treated like a person anymore but like a “disease case”, and it could say that the patient concept almost disappeared from the hospitals concerns. The modern life was blamed to be the source of illness, society as a whole was seen as sick and the ‘medical fortress’ was an accomplice. This views turned the scene around, where society had to shift from institutional power to citizen power, and this had a huge impact inside the hospital, where patients became the main actor

Hospital San Pau, Barcelona Lluis Domenech i Montaner 1902

22

Paimio Sanatorium, Finland Alvar Aalto 1929

Beaujon Hospital, France Plousey, Cassan, Walter 1933

Maimonide Hospital, Sn Fco, USA Erich Mendelsohn 1946

100

Princess Margaret Hospital, UK Powell, Moya 1957

1960

Health Suburb

1950

Functionalism

1940

Monumental

1930

Modernism

1920

Art Nouveau

Pavillion Hospital

_X Rays

in the new system: patient-centered care.

This new shift pointed to a more natural society,

plished, though shopping and social activities where under

giving the importance of the physical and social environ-

the same frame, this were very different from the medi-

ment for the well-being of people. So the challenge of the

cal side, now the border was inside the hospital ground,

new hospitals now was quite different: it was a balance

instead of actually blurring the limits it was just a matter

play between the individual and the collective; the per-

of disguise.

sonal experience of the patient and the medical needs of the staff. The answer for this new approach was the installation of basic, industrially built structure that would work as a neutral framework where more individualized components could be inserted, tackling the core of the hospital’s problematics. This “style” also had other concerns, beyond only the hospital building itself, but its urban role.

Stepping away from the monumental big scale building, there’s mostly low rise buildings. This new projects try to read the large scale grid, and integrate to the urban tissue. The hospital grid tries to follow the surrounding city, becoming unrecognizable as a single building or institution. The strategy is to develop really flexible structure, for the same reason they must be neutral and inexpressive, the function of today won’t be the same as tomorrow, so the frame shouldn’t express neither. Another turn was the differentiation of the medical machine and the flows of visitors and patients, during the 80’ and 90’ hospitals where recognized by large halls and passageways, covered street and squares. This is the time where shops and urbanity jump inside the hospital structure, accompanied by change in the management vision, the hospital became more a social place than a medical one. But this attempt

Vienna General Hospital, Austria 1784

Erasmus Hospital, Rotterdam, NL Medicine Faculty Rotterdam 1972

St. Mary’s Hospital, Newport UK Ahrends, Burton, Koralek 1982

2010

The inner Street

2000

City in the City

1990

Energy Issue

1980

200

1970

0

Hospital City

to take part of city urban life, wasn’t completely accom-

Univ. Medical Center, Groningen, NL UMCG 1997

23

THE HOSPITAL NOW:

The New Mission and Challenges of Today.

NATIONAL POLICIES

After studying the journey of this emblematic institution the only thing that can be seen as permanent has been the continual change, not only in shape and strategies, but in its

?

core. Because of this continuous shifts it feels sometimes that hospitals are, one step behind or are just a bit too late to meet current needs of society. That maybe is because a hospital project is planned to be long term, taking into account that the life

REGIONAL POLICIES

EDUCATIONAL CAMPAIGN

W H A T TO DO

TRANSPORT SYSTEM

cycle of one of this structures is of 50 years. Lately, as most

COMMUNAL PROGRAMS

technical areas, has been growing and changing at much higher rates than ever, leaving us with a complex scenario.

SOCIAL INICIATIVES

WELLNESS INFRASTRUCTURE

The hospital as a building has been adapting to time, but

FOOD INDUSTRY

without a complete solution. We can go back to the beginnings of the modern hospital in the enlightenment, where rationality ruled the guidelines and nature had an important healing role, but the patient was not the focus, but its illness. After, modernity creates the most efficient hospitals, but falling into the trap of giving life to a machine, more focused on its functioning that

“Hospital mirror and project the consciousness and acceptance of responsibility of its society” The Zitgeist

what this engine was producing. Then we come to today, due to high regulation and the current bureaucratic apparatus, hospitals have been victims of lack of planning and power games, becoming complex messy buildings instead of better buildings.

The System itself is portrait in this kind of patchwork inside the institution, building from different times without any main

GREEN HOSPITAL

guide, just stacked together as the needs appear. Creating intimidating fortresses filled with a riddle of corridor mazes run by bureaucracy. This anonymous institutional complexes are hardly ever functional, and most of the time are unfit for its purpose, resulting in high factors of stress and anxiety, which undermines the patient’s recovery. This scenario is the result of an reactionary attitude toward health and well being, leaving the big pictured blurred for anyone to see, guiding blind throw

FREE MARKET HOSPITAL

HIGH TECH HOSPITAL

COMMUNITY HOSPITAL

contingency.

?

WHERE TO NOW

CLIMATE FRIENDLY HOSPITAL

WELLNESS HOSPITAL

ENERGY EFFICIENT HOSPITAL

24

HOLISTIC HOSPITAL

OUTSIDE THE OUTSIDE CITY THE OUTSIDE CITY OWNING OUTSIDE THE CITY THE OWNING THE CITY CITYTHE OWNING CITYALIEN THE OWNING IN CITY THE ALIEN THE CITY CITY IN THE ALIEN CITY IN BECOME THE ALIEN CITY THE INBECOME THE CITY CITYTHE BECOME CITY THE BECOME CITY THE CITY

Hospital and the City

ity onto one person, but also creates the ghost of uncertainty

Today Hospitals face again a turning point, where not

of work. All that comes to the most serious matter how it is

only the building is being questioned but the system at large.

mental health.

More and more, the view of the hospital as a city has come

In Sweden from the 90’ sickness absence and disability

through, and the will to integrate to the urban tissue is dominat-

retirement caused by mental problems and disorders have risen

ing, but what does this aim to? Is not about systems and repli-

markedly. Concepts such as burnout, depression and chronic

cating a model, it goes beyond that. The ultimate characteristic

fatigue syndrome have been used increasingly in the media and

that comes out from a good design city and what is lacking in

are now part of everyday language.

the healthcare area is integration that is a direct result from a

These phenomena are probably the result of prolonged

living and active community. Which will translate in to a social

stress processes, and the biological and medical risks of pro-

engine that will create a true platform for social, economic and

longed stress have been highlighted recently (Lundberg & Wen-

cultural integration, because health has never been an individual

tz 2004). Signs of reduced mental well being therefore deserve

matter but a social one, and for that it has to be understood as

attention, since they may develop into serious health risks in

part of a bigger picture. Is mistakenly believed that if a hospital

the long term.1

is located in an urban setting, this will be a guarantee for its integration, but this is a complete error, consequence of the lack

Green Hospital

of understanding of the complexity of the health landscape. The

As time goes “Green” approaches have appear in every

aim of re-urbanizing hospitals is not only so they fit in the city

area and hospitals are no exception. Though is very true that

on a functional way, but also to has to overcome built obstacles

certification and regulation helps keeping matters in order, and

and finally connect physically to the city. One example of this

is a visible way for institutions to show their investments and

is the University Medical Center Groningen, where even though

standards to the community their serving, and in that way gain

is on a urban location its surrounded by built barriers and the

its trust.

only place that opens up, is in a monumental entrance hall with a “public plaza” towards a highway instead than the city itself.

Until the mid 90’s hospitals and health care facilities enjoyed a deceiving reputation the cleanest buildings, where people didn’t question their neatness, but after an eye opener re-

Industrialized Hospital

port issued by the US Environmental Protection Agency, where

One criticism often voiced is the ‘industrialised’ nature

medical waste incinerator, over 5.000 in North America, turned

of care, heritage of the machine hospital of the modernists still

the red alarm becoming the single biggest source of dioxin emis-

alive to this times. The high working pressures often put on the

sions into the atmosphere. With this all heath institutions where

staff can sometimes exacerbate such rushed and impersonal

put on the spotlight, and their attitude towards environmental

treatment. The architecture and setup of modern hospitals of-

policies and strategies had to change from a quite passive one,

ten is voiced as a contributing factor to the feelings of face-

to a more active one, giving the industry the chance to lead the

less treatment many people complain about. The high stress in

needed change.

health workers, not only affects their work and health but also contributes to the already stressful experience of the patient.

Hospital are not only expensive, but also highly polluting and stress producers.

According to a report about Work life and Health in Sweden

Today the Healthcare sector is growing fast, and many

done by the National Institute for Working Life almost 40% of

eyes are on it for its big impact, not only social, but also eco-

the health workforce is under an “unhealthy” work situation. In

nomical, political and ecological.

Now is the time where we

addition to that, most of budget cut in health are solve by per1 Worklife and Health in Sweden 2004. Rolf Å Gustafsson,Ingvar Lundberg

sonnel reduction, that not only puts more work and responsibil(eds.)

25

have to realize that they are part of an ecosystem, and so are all human creations. Its being proven that our wellbeing is directly related to our environment, and for that we are not only linked to the ecosystem around us, but part of it. This means that our well being is directly related to the environments well being, and you can’t have one without the other.

A hospital or any health institution can see that they can no longer think of themselves as an isolated island, exempt from its urban ecological context.

We have come to a point

were healing the individual is directly connected to healing our planet. I might sound a bit to general or heroic, but no society will ever have healthy individuals, healthy families or healthy communities if there is no clean air, clean water and healthy soil.

Health care institutions should not build to meet a label, since they will change with time, but use the existing resources and make it efficient. The existing health infrastructure is there and is huge, the impact on the overall system, if they would be used, upgraded and renovated with a long term vision, it would be more efficient that burying them and build new. The value of the existing structures is great, not only for its cost and material, but for its location and existing relation with the city.

Hospital as a Social entity Hospitals are today barely alive and serving its purpose: healing sick people, though the purpose also has to change. Is being sick wasn’t bad enough, patients are obliged to go to this intimidating place where they are stripped of any privacy, suffer

Hospitals in the US have “enormous carbon footprints”, being the second most energy intensive building type behind that of the food service industry and twice that of commercial buildings.

They are “extraordinarily water intensive”, averaging about 300 gallons per patient per bed per day when there is a desperate need to reduce the water footprint.

The National Health Service (NHS) in England has calculated its carbon footprint at more than 18 million tons of CO2 each year — 25% of total public sector emissions.

Brazilian hospitals use huge amounts of energy, accounting for more than 10 % of the country’s total commercial energy consumption.

of long waiting times, are exposed to uncontrollable noise and get separated from family, taking into account that from the

Towards a Green Hospital

start people in a hospital are already low in spirit hospitals today

Speech held by Dr. Wolfgang Sittel at the Asia Pacific-

only manages to get that spirit even lower, not only for patient but also for the already overwhelmed staff.

Hospital staff is mostly disregarded in the discussions and are seen as a pressure group, difficult to negotiate with, but they are the direct link between the “machine” and the patient, they are the face of the system and the change starts with them. Nurses and doctors have the opportunity to touch peoples life, making them important agents for changing thinking, behaviour, communities and patterns. The importance is to not forget that Health care is health+care and that show be the guide line for every decision and action.

Now they are work as Medial Health Centres for the Individual, but they must take the leading step towards the paradigm shift: Heath is not individual but collective. The challenge for hospitals is to walk away from just being a building but a leader of change and education, which is also the key in the prevention of disease.

26

Weeks in Berlin.

September 8ht 2011.

GOVERNMENT

MANAGMENT

DOCTORS

INSURANCE COMPANY

PATIENTS

HEALTHY PERSON

HEALTHY HOUSEHOLD

+

EDUCATION

HEALTHY CITY

NURSES

CURRENT PURPOSES FOLLOWED BY HEALTH CARE SECTOR: HEALTHY HOSPITAL

Enhance communication between referring physicians and the hospital, improve team communications, streamline patient ямВow, and decrease waiting time and overall length of stay.

27

H

Heal: ‘To restore to health’ ‘To cause an undesirable condition to be overcome’

THE HEALING ENVIRONMENT Upcycling the OLD for a healthier NOW

HEALING ENVIRONMENT: What to take into account.

It is been a couple of decades now that hospitals have been criticized for its poor spatial qualities and disregard towards the patient, who is supposed to be in the genesis of it core. And how it always works, if something gets criticized proposals have to be suggested, is in this dynamic that the concept of healing environment was created. But this shouldn’t be taken lightly, because as its name says: the environment has to heal.

STAFF

But how do we know that? For that a method is needed.

Healing environment: describes a physical setting and organisational culture that supports patients and families through the stresses imposed by illness, hospitalization, medi-

PATIENT

HEALTHY SPACE

cal visits, the process of healing, and sometimes, bereavement.

During the second half of the last century, medicine took a scientific turn, in hand with evidence based medicine, the whole field moved towards research, which is by the way today, one of the biggest areas in the medical community not only for it reputation but also because is highly financed, from that hospitals couldn’t function without a research branch in their system.

After World War II not only medicine was advancing in the research field, but from the contingency of the time environmental psychology stepped up, raising new discoveries but also new questions. Is during the 80’ when the architect and researcher Roger Ulrich saw in this investigation a rich source of data, through a report exposing that surgery patients with a view of nature suffered fewer complications, used less pain medication, and were discharged sooner than those with a brick-wall view, and with this the effects on people of a certain environment started to be measured.

Rooting from this scientific approach the hospital’s critics had something to work from, and now evidence could support decisions not only in the field of architecture, but also designers and managers. Everything started to be measured: clinical outcomes, staff efficiency and patients impression; since this was an empirical approach, replacing philosophical matters, opinions and suggestions weren’t regarded because of their lack of objectivity, instead only “first reactions” were used as firm data,

30

VISITOR

PATIENT: -Need of privacy -Need to socialize with others -Healing Environment; Indoor+Outdoor

“ As a patient, I want a private and comfortable room which has supportive environment but flexible and have lots of function such as sit, stand, low-down and look outside. Outdoor environment must be quite good, the I can have a good view.

A flexible space that could change quite easily and I can get all the things quite easy and cured. A private room should be good but sometimes I want to communicate with other patient, doctor or nurse. So it may be just half-open. The room should be a good place to release my stress and pressure, as comfortable as my home.

Also it should be a quiet place, cause I don’t want to hear other patients moan in my room. Some connection with nature is needed, I know that I can’t be outside, but I want to see nature.”

STAFF:

VISITOR:

-Need accessibility to corridors and rooms -Comfortable Working environment -View to outside/ Relation to time and space

-Smell of hospital -Walking through the corridors -Comfortable place to relate to the patient

“John gets home at 6 am. Takes the grocery list from his wife who’s leaving for work. He has to dress his son that also got a cold thanks to the germs he brings home, he hates night shifts. He drops his son off, does his groceries and tries to catch a few hours of sleep. Even after all the years he hasn’t managed to adjust to the shift. Wakes up in time to make dinner and fetch his son from school. He waits for his wife and hopes she comes in time or he will have to leave his son at the neighbours. She comes. They exchange a few words and off he goes. He will be going straight to the hospital from her elderly home for yet another night shift.

“Bob can meet his mother from 10 to 1 o’clock, then his mother goes to lunch. Then he’s able to see her from 3 to 7 in the evening. After work goes to the shop to buy some things for his mother and goes to the hospital, already being around 5. He can meet a lot of visitors, cause most of them can only make it after work.

He feels very unpleasant smells and sees very sick patients. He’s afraid of that and of the possibility of getting something himself. After passing several floors and corridors, he reaches the ward where his mother is. There are other people in the ward, so they can’t have a normal chat. They can go to the yard and talk more privately and have a walk.

31

though with time this has been also questioned.

factors is stress reduction. It was discovered that over the exist-

After building data and analysis of results, by publica-

ing stress experimented by medical procedures, many features

tion on different matters, Evidence based Design (EBD) could

of the same hospital actually help increase the environmental

be implemented in new projects and renovations through out

level of stress for the patient.

the globe. This as a tool was perfect for architects to convince

The reduction of stress is not important just for reducing

their clients, Institutional managers to guide their boards and

stress itself, but for the side effects that come with it, not only

medical staff to demand changes. The body of research and in-

for the patient but also for the staff and physicians .Shorter

formation is building day by day and not only that, it is getting

outcomes, less medical errors and fewer prescribed medication

updated, which present a new challenge: what was efficient or

are some of the benefits that addressing stress can mean for a

preferable yesterday, might not be today.

health care facility, so it’s not only a better service but a more

As every architectural approach EBD has to respond to

economic one also.

a multi-sensorial demand, in its core regards the health impact of a particular environment on patients, staff and visitors as a

Research has proven that the actual design can influence

guiding principle of design. So from Ulrich’s connection between

medical outcomes by mitigating stress or increasing safety,

view and pain, many studies and researches were made for dif-

that is why the focus today for most facilities are : reduction

ferent factors as light, colour, sound, control and distance. After

of stress, patient and staff safety, and energy and resource ef-

many actions were implemented in different settings the main

ficient building.

factors for comparing results and weight its validity are: patient

So what does a healing environment consist of? The

clinical outcome, staff recruitment and retention and facility op-

main considerations that are mostly agreed in the overall com-

erational efficiency.

munity are:

Though many factors are in play at the time of recovery one that showed to be one of the most influential in all three

32

_Connection to nature, Option and Choices, Positive Distractions, Access to social support, Environmental stresses

NATURE The view or perception of nature brings the patient a sense of calm, reducing stress levels.

POSITIVE

LIGHT The view or perception of nature brings the patient a sense of calm, reducing stress levels.

NOISE Its reduction affects not only in the patient but also the staff, translating in less stress and medical errors.

SAFETY Secure environment reduces stress, but in a higher degree avoids unnecessary injuries and complications.

SOCIAL SUPPORT Is an important factor for patients to feel at ease in a new environment.

D I S -

TRACTION Elements like art and activities help to scape from the hospital environment, creating a break in the routine.

AIR Air transmitted infection is a serious issue, since is a high factor for extending stays due to new complications.

CONTROL Is an important factor for patients to feel at ease in a new environment.

33

HEALING ENVIRONMENT: Factors and Effects.

Stress Though is a very normal condition, today’s levels of stress are not only higher but also present in a larger group. The known risks, that everyone has experienced at least once, are only the superficial signs of more relevant effects in the body. On top of everyday stress, patients accumulate a higher level provoked by anxiety, confusion, fear and worries provoked by the medical procedure and clinical environment. One of the characteristics less know about stress is probably its duration that can last for hours after an stressful event. Independent from the procedure stress produces a hormone that also lowers the threshold of pain, giving the patient a higher pain sensation.

But this condition actually not only affects the patient but in great measure affects the medical staff. By overloads of responsibility, lack on material and staff, and inadequate facilities for the required tasks, health workers become a highly stress group, which is directly transferred to the patient, creating a vicious circle.

BRAIN AND NERVES Headaches, feeling of despair, lack of energy, sadness, nervousness, anger, irritability, increased or decreased eating, trouble concentrating, memory problems, trouble sleeping, mental health conditions, such as : panic attacks, anxiety disorders and depression.

SKIN Acne , irritation other skin problems.

MUSCLES AND JOINTS Muscle aches and tesion, especially in the neck, shoulders and back. Increased risk of reduced bone density.

HEART Faster heartbeat, rise in blood preassure, increased risk of high cholesterol and heart attack.

STOMACH Nausea, stomach pain, heartburn, weight gain.

PANCREAS Increased risk of diabetes

28%

of health care workers report a higher than average degree of stress compared to 18% of the general population.

bmj.com

34

INTESTINES Diarrhea, contipation and other digestive problems.

REPRODUCTIVE SYSTEM For women: irregular or more painful periods, reduced sexual desire. For men: impotence, lower sperm production, reduced sexual desire.

INMUNE SYSTEM Lowered ability to fight or recover from illness.

Noise Frequent overhead announcements, pagers, alarms, and noisy equipment in or near patient rooms are stressful for patients and interfere with their rest and recovery.1 Single-bed rooms with high performance, sound-absorbing ceilings and limited overhead announcements can substantially improve the healing environment for patients.2

1 Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF. 2 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.

Errors & Safety Medical Errors: Poor lighting, frequent interruptions

two primary causes of patient falls. Many falls can be reduced

and distractions, and inadequate private space can complicate

through providing well-designed patient rooms and bathrooms

filling prescriptions. Well-illuminated, quiet, private spaces al-

and creating decentralized nurses’ stations that allow nurses

low pharmacists to fill prescriptions without the distractions that

easier access to at-risk patients.4

may lead to medication errors.

Patient rooms that can be adapted for the acuity of a patient can also reduce errors. Acuity-adaptable rooms reduce

4 Transforming Hospitals:Designing for safety and Quality. Agency for Healthcare and Quality, US. 2007

the need to transfer patients around the hospital and lessen the burden on the staff to communicate information to caregivers in the patient’s new location.3 Patient falls: Patient falls, which are common in hospitals, can result in serious injuries, extend a patient’s stay, and drive up the cost of care significantly. By 2020 the estimated annual cost of fall injuries for older people will exceed $30 billion. Now that the Centers for Medicare and Medicaid Services no longer reimburse hospitals for the cost of patient falls that occur in their facilities, and insurers are likely to follow its lead, hospitals will bear a greater portion of this cost.

Poor placement of handrails and small door openings are 3 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.

35

INFECTION Single-bed rooms and improved air filtration systems can reduce the transmission of hospital-acquired infections.

Infections can also be reduced by providing multiple locations for staff members to wash their hands so they spend less time walking to sinks and have more opportunities to sanitize their hands before providing care.5 One of the most effective measures in to have a sink in every room entrance, in plain sight and in the nurses working path for accessibility and also the patient can supervise the medical staff’s cleaning habits.

5 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.

NATURE On a first approach we can all agree the looking at na-

Environmental preference studies have shown that a

ture has a tranquillising effect and that it provokes a positive

natural setting is the view of choice. Charles A. Lewis refers

outcome in our current condition, for patient it has been proven

to it as “green nature”(Spriggs et al., 1998). Gordon Orians

that this is more than just a personal impression but a fact:

and Judith Heerwagen, in their studies on landscape aesthetics, have shown that people prefer open, distant views with scat-

“a view nature on a screen or view can reduce stress and pain”

tered trees, water, and refuges and paths that suggest ease of movement. In studies of users of some urban parks, properties

“Indoor Plants lift people’s mood and reduces self-reported symptoms of physical discomfort”

such as vegetation, water, and savanna- like qualities, such as scattered trees, grass, and spatial openness, seemed to cor-

Healing By Architecture,

relate with ratings of restoration (Ulrich and Addoms, 1981). In

Agnes Van den Berg and Cor Wagenaar.

his article, Healing Words, J. William Thompson quotes experts in the field of healing garden design:

Several theories have evolved to address the question of Nature having a “healing” or restorative condition. In learning

“Anything green makes patients feel better, any plant,

theories, the subscribers suggest that man has learned to pre-

any tree,” and “…if they wish to create truly healing spaces,

fer nature. For example, people may have learned to associate

landscape architects would do well to discover – or rediscov-

restorative experience with nature because of vacations spent

er—the wonder of the plant kingdom”

in beautiful settings or long childhood summers spent on the beach, or near a lake or stream.

Urban settings, on the other hand, bring back images of traffic, congestion, work pressure, filth, or crime. Cultural theories propose that we are taught by society to have positive feelings towards certain types of environments. For example, Native American and Asian cultures have taught their peoples to respect nature.

36

Landscape Architecture, Jan. 2000:54-75

37

LIGHT Probably one of the most abundant resources and with high impact in patient recovery is daylight. Though daylight is recommended, sunshine must be controlled, avoiding glare and too much reflection on the patients bed. There are many factors that will determine the light situation in a project and is needed to take them into account: (northern hemisphere guides)

GUIDELINE 1 Orientation and Location The direction of the building will determine solar gains in radiation, though this must be determined also by the particular climate zone, the specific site, an external factors present in the place. Is not possible to define a universal orientation for healthcare buildings because of functional and individual characteristics, but is possible to define advantages and disadvantages of different orientations: NORTH-SOUTH: The negative is that minimizes the souther, and

Patients to an increased intensity of sun-

most preferred facade. But it avoids the northern faced rooms,

light experienced less, perceived stress, less

giving all some light during the day.

pain, took 22% less analgesic medication per

EAST-WEST: Maximizes desired southern facades with simple

hour and had 20% less pain medication costs.

and easy sun control strategies. Creates a clear distinction with norther facades, that will not get any direct sunlight.

GUIDELINE 2 Sun Control As paradoxical as it sound, the worst enemy of daylight is the sun itself, that is why efficient and thought strategies for shading must be implemented, to avoid heat gain and glare. This strategies will take effect mainly in the southern (all day) and western (afternoon) facade. The role of the system is to control thermal and visual comfort of its occupants and to support the heating and cooling system loads. Since the sun is an always moving source, not only throughout the day but during seasons, is necessary not only to shade but to control and redirect the given light in an efficient manner to the interior of the building.

38

Ulrich, 2004.

ACCESS TO DAYLIGHT AND VIEW TO NATURE IMPROVES RECOVERY PROCES

DAYLIGHT REDUCES ENERGY CONSUMPTION

BRIGHT LIGHT MAY RESULT IN FEWER ERRORS

MIGHT INCREASE PRODUCTIVITY, STAFF SATISFACTION AND REDUCE TURNOVER

DAYLIGHT AND HEALTH REDUCE LENGTH OF STAY

MORTALITY RATE

Room without direct sunlight

Room with direct sunlight

North facing room

19.5%

16.9%

_Beauchemin, K.M. & Hays, P. (1996). Sunny hospital room expedite recovery from severe and refractory depressions. Journal of Affective Disorders, 40 (1-2), 49-51.

MEDICATION COST

South facing room

16.9%

More pain

Less pain

16.9%

_Beauchemin, K.M. & Hays, P. (1996). Dying in the dark, Sunshine, gender and otcomes in myocardial infarction. Journal of the Royal Society of Medicine, 91(7), 352-354.

22% LESS _Walch, J.M., Rabin, B.S., Day, R., Williams, J.N., Chai, K.,& Kang, J.D. (2005). The effect of sunlight on post operative analgesic medication usage: A prospective study of spinal surgery patients.

Psychosomatic Medicine, 67 (1), 156-163.

DAYLIGHT AND ECO-EFFICIENT THE NEED OF REDUCING ENERGY CONSUMPTION: HEALTHCARE ARCHITECTURE AND GLOBAL HEALTH

GREENHOUSE GAS EMISSIONS. Comparison between hospitals in U.S., Germany and Norway.

With appropriate control for HEAT GAIN and GLARE, daylighting has the potential to reduce energy consumption needed for lighting ENERGY USE IN HEALTHCARE FACILITIES

ELECTRICITY CONSUMPTION 13% of electricity consumption is used for lighting.

Space Heating Cooling Ventilation

_Burpee, H., et al., 2009. High Performance Hospital Partnerships: Reaching the 2030 Challenge and Improving the Health and Healing Environment

_Energy type used in Health care buildings in the U.S. US Department of Energy.

_Electricity Consumption (Total BTU) by End Use for Healthcare Buildings in the U.S. in 2003. Released 2008 (US Department of Energy information Administration)

Office Equipment Computers Other 120

_Arqum Gesellschaft für Arbeitssicherheits/Qualitäts- und Umweltmanagement mbH (2008).Abschulssbericht zum durchgeführten Projekt "Energieeffizienztisch" für Krankenhäuser in Rheinland-Pfalz

Lighting Cooking Refrigeration

40 % Electricity

100

_Data from U.S. National Database: The Commercial Buildings Energy Consumption Survey (CEBECS)

Water Heating

60 % Fuel

80

Average carbon dioxid emission of Norwegian Hospitals. (Rikshospital and St. Olavs)

60

127 KBtu/SF/year= 52 lb CO2/SF/year

Average carbon dioxid emission of German Hospitals.

40

104 KBtu/SF/year= 43 lb CO2/SF/year

Average carbon dioxid emission of U.S. Hospitals.

0

280 KBtu/SF/year= 116 lb CO2/SF/year

BTU

SAFETY DAYLIGHT CAN BE USED TO IMPROVE ILLUMINATION LEVELS. HIGH ILLUMINATION LEVELS MAY RESULT IN FEWER ERRORS .

!! !!

3.8%

error rate

!! !

2.6%

error rate

_Buchanan, T.L., Barker, K. N., Gibson, J.T., Jiang, B.V., & Pearson, R.E. (1991). Illumination and errors in dispensing.

American Journal of Hospital Pharmacy, 48(10),2137-2145.

DAYLIGHT SOCIAL/ECONOMIC BENEFITS DAYLIGHT CAN BE USED TO IMPROVE ILLUMINATION LEVELS. HIGH ILLUMINATION LEVELS MAY RESULT IN FEWER ERRORS. Though building a highly perforated building may be more costly, this investment will translate in several long term benefits and savings for the institution such as energy savings. But on another level there is a great potential to reduce the cost related to staff members by increased satisfaction, reduce stress levels and increase productivity and concentration, which results in lower medical errors rates.

Daylight in a workplace is the most preferred source of lighting.

(Mrochzek et al.,2005)

Environmental satisfaction is high if is more likely that overall satisfaction in hospitals will be also high.

(Harris et al., 2002)

Nurses being exposed to daylight for more than 3 hours during their work showed less perceived stress, higher job satisfaction and lower intention to quit in comparison to nurses with a daylight exposure less that 3 hours per day.

(Alimoglu,M.K.,& Donmez, I.,2005)

39

CONTROL To reduce anxiety on the patient is necessary to reduce its sense of lack of control, by giving them the needed information an tools to make decisions and prepare themselves for following tasks or procedures. Most of the times patients are carried through the building with no clear explanation of where they are or where they are going, creating an unclear an frightening scenario. Intuitive wayfinding, ceilings is what patients sees, so there must be effort in strengthening these aid and also creating a readable space, so is not necessary to explain everything but the building becomes self explained.

Helping patients effortlessly find their way through hospitals can improve patients’ overall care experience and increase satisfaction by reducing feelings of stress, anxiety, and helplessness for them and their families. Better navigation can be addressed architecturally through useful signs and easily navigable corridors.6

6 Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.

7,4%

3,0%

1,3%

COLOUR

32,2% 19,9%

Colour is a non built element that really impacts the space, 36,0%

most of the time is disregarded as a secondary and decora-

relates to certain shades, evoking medical treatment. Nowa-

Patient Room

12,05%

days after many polls and interviews with user is known that

% 3,8

the elements that is characteristic for a hospital, where people

6,27%

2% 2,7

tive role, without weigh-in its possible effects. Is also one of

6,0%

12,4%

39,95%

39,6%

15,2%

though white is preferred through out the different spaces, the

23,1%

use of colour is now recommended, avoiding huge planes of a

Work Places

24,23% %

The colour is also a powerful tool for orientation, information and spatial clearness.

8,2%

3,0

plane washed out colour for more intense but confined ones.

8,8%

14,78%

34,3%

17,0% 28,8%

Corridors

8%

2,

7,9%

19,6%

Graphics of the ideal colours to use inside the Ward according to the personnel.

(Source: Research Project Working-Place Hospital)

40

53,7%

7,09% 9,0%

Sanitary Facilities

PATIENT ROOM The room must be one of the most important places in a hospital, is where the actual healing takes place. Small space full of small decisions, like having a broader free space on the entrance side of the bed for easier medical access. The role of distances play a huge role, specially the one toward the bathroom, not only should be short but also continuos surface from the bed, to avoid falls.

Single room are in demand, because of infection but also practical issues: reduce risk of infection, stress from noise and transfer rates which is a high cause of medical errors. Also is more comfortable to welcome the family.

41

EVIDENCE BASED DESIGN

Guidekines and Method by Research

Healing Environment: Is the result on a EBD that has demonstrated measurable improvements in the physical and/ or psychological state of patient and/or staff, physicians, and visitors.

Should make a therapeutic contribution to the process of restoring someone’s health. For what it should be more than just intuition (most practices) it has to be proven with on site field research and answer: Who was healed? How do we know?

EBPractice: designers make critical decisions together with an informed client, on the basis of the best available information from credible research and the evaluation of completed projects.

Performance Based Building Design (PBBD): attempts to create clear and statistical relationships between design decisions and requirements satisfaction levels evidenced by the building systems. PBBD uses research evidence to predict performance related to design decisions. However, the decision making process is not a linear one: for the build environment is a complex system. Choices cannot be based on simple causeand-effect predictions; instead they depend on many variable components and on the mutual relations established one each other.

Four Levels of Evidence-Based Practice Level 1:analysing the literature in the field in order to follow the related environmental researches reading the meaning of the evidence in the relationships to the project Level 2: foreshadowing the expected outcomes of design decisions upon the general readings measuring the results through the analysis of the implications, the construction of a chain of logic connection from decision and future outcome, in order to reduce arbitrary decisions Level 3: reporting the results publicly, writing or speaking about results, and moving in this way information beyond design team subjecting methods and results to others who may or may not agree with the findings Level 4:publishing the findings in reviewed journals collaborating with academic or social scientists

42

PHYSIOLOGICAL IMPACTS

PARAMETERS

ELEMENTS FOR DESIGN

Healing

View

Site

Pain

Light

Orientation

Art

Infection

Layout

Cardiac Rhythm

Colour

Functionality

Exercise

Sound

Interiorism

Admition time

Airflow

Materials

Medical Errors

Privacy

Equipment

Accidents PHYCHOLOGICAL IMPACTS

Social Rooms Acces to nature Safety

Comfort

Envelope Flows Connections

Wayfinding

Orientation

Hygiene

Economical Control Satisfied Staff

Current Hospital design is

These

parameter

summa-

Though the architectural el-

focused on analysing the dif-

rise the quest for a better and

ements don’t change much

ferent impacts that their ac-

healthier environment. Creat-

from a traditional project, the

tions can improve or create.

ing a strong set of guide lines

relations change. Is important

EBD bases all its knowledge

for the design process, that

to bring to surface the hidden

in the analyse and research

comes as a result of system-

links and be aware of the end

of this mostly quantitative ef-

atic research, revealing hard

results that a single decision

fects, because of its scientific

data and trustworthy param-

can achieve. Many practical is-

approach, for the rest environ-

eters meant to be addressed

sues are mostly regarded, but

mental psychology plays an

at the project.

the relation to more soft val-

important role, backing up the

ues show an important role on

knowledge.

their impact.

43

H

“... built catastrophes, anonymous institutional complexes run by vast bureaucracies, and totally unfit for the purpose they have been designed for ... They are hardly ever functional, and instead of making patients feel at home, they produce stress and anxiety.”1

1 a b Healing by design – Ode Magazine, July/August 2006 issue. Accessed 2008-02-10.

MALMÖ HOSPITAL Maximize the OPPORTUNITIES within an EXISTING building

MALMÖ UNIVERSITY HOSPITAL History and Context

The Hospital was founded in the outskirts of the city, as a green complex almost as a continuation of Pildmmsparken.

The Pavilion arrangement followed that premise, as an open arrangement standing in a park like site.

Nowadays the hospital stands where the city has been growing and expanding.

1812

It is split by a former urban limit , as is the road that connects the airport and the city. As a response, the complex was densified in the same “free standing building” scheme, but without following any urban logic.

1912

1939

46

2010

Rigshospitalet Copenhagen University Hospital 46,5 km 43 minutes

Lund Hospital Lund University Hospital 20,5 km 18 minutes

N NNW

NNE

NW

NE

WNW

ENE

W

10

15

WSW

ESE

SW

N

SE

SSW

NNW

SSE

S

NNE

NW

Average wind direction, (km/h)

NE

RH, Precipitation

Temperature

(percentage,cm)

(Celsius, C) January

WNW

ENE

January

December 20

December February

80

15

60

November

5

10

15

E

20

February

70

10

November

W

E

20

50

March

March

40

-5

30

-10 -15

October

WSW

April

October

April

ESE

0 2

SW

September

SE

SSW

September

5

May

SSE

August June

S

July

(percentage,cm)

(Celsius, C) January

December February

80

15 10 5

39

January

December

November

Rh, Precipitation, (percentage/cm)

RH, Precipitation

Temperature

20

June July

Temperature, (Celcius)

Average wind direction, (km/h)

May

9

August

70 60

November

50

February

47

MALMÖ UNIVERSITY HOSPITAL Vision

The mission is to develop a sustainable plan for the hospital in Malmö. The hospital’s physical environment and structural engineering status have been investigated. Existing buildings can not meet future requirements for high-tech care, such as surgical and intensive care. Current health care buildings have little opportunity be converted into units of one-patient rooms, but should be in less term to serve as day care and reception. Mature where buildings need to be supplemented in order to serve as administrative premises. Some Hospital Activities today are rented premises on the South area and Sege park will eventually move in and be assured a place in the area.

Hospital district of Malmö, the region’s largest employer, centrally located in Malmö and with close links to the City Tunnel.

A well-developed City of integration synergies and development opportunities for both Region Skåne and Malmö City. Ongoing planning work with this starting point and a common mission statement has been established in cooperation between the City and Region Skåne. Region Skåne Ongoing planning activities are primarily designed to establish a robust development structure for the hospital area and to study a number of areas or development scenarios, which can form the basis for detailed planning of future expansion phases. Proposal for overall planning and design details of this Property Development Plan have been addressed in a number of working meetings between the project team and City Planning To develop a modern hospital with high demands on functional relationships at all levels in the surrounding urban environment is a major task. The buildings must be integrated into the surrounding neighbourhood structure, creating attractive human environments and enhance the architectural values​​. City Tunnel up from Triangeln way is on blocks just north the hospital and

48

others fate of this hub for public transport ken and the hospital should have an obvious and clear design.

A new service terminal proposed in the southeast corner of the hospital campus with entrance from John Ericsson path. Where f NNS also able to place certain technical services and other operational functions. The block is strategically in relation to transportation and an extensive culvert system.

The proposed coherent block structure of the hospital campus occur as a result of the concentration of the medical care activities, more perifical area that can be utilized by other functions.

The extent of these surfaces is dependent on strategic decisions regarding Hospital maximum size in the long term.

By allowing an area to be undeveloped, the hospital has the facility to incorporate an elasticity in the range especially at operations and for future reference. It is therefore important that the hospital’s control This “reserved” zone.

The proposed planning will be characterized by: an integral and natural part of the city, organized in a concentrated development of a coherent block structure. The communication structure for traffic, cycling and walking should be clear. A comprehensive green structure will characterize the area.

49

MALMÖ UNIVERSITY HOSPITAL Analysis and Mapping

The hospital is a machine that works in a closed circuit, having nothing to do with it’s surroundings. Today, the concept of hospitals as islands, separated from context it’s blurring and becoming more permeable to the city. The idea is to discover this connections, present and hidden. Once knowing this, it’s possible to propose new links and improve the existing ones, with a series of measures.

The site is conformed by singular buildings connected during time. The configuration is different from the urban block, but it continues the floor density as the surroundings, becoming a part of the city, with is own neighbourhoods and streets.

Buildings are all around the plot. The highest density is on the center-north part of the hospital, where the patients and the treatment and diagnostics are.

The Hospital was founded in the outskirts of the city, as a green pavilion complex almost as a continuation of Pildmmsparken. Nowadays the hospital stands where the city has been growing and expanding.

Split by a former urban limit, now the airport road. As a response, the complex was densified in the same “free standing building” scheme, but without following any urban logic.

50

51

MALMÖ UNIVERSITY HOSPITAL Analysis and Mapping

52

REAL SITUATION: Entering the Hospital

REAL SITUATION: Discovering the Core

REAL SITUATION:

Near Future Expansion Plans

53

MALMÖ UNIVERSITY HOSPITAL Strategy and Masterplan

As a general strategy to connect the parts and ares of

branches. The idea is to strengthen the network by creat-

the hospital, we decided to revitalize the existing under-

ing a “main line” that connects the supply-service area

ground system, that lacks of spatial qualities but performs

with the treatment-patient area.

an essential role in the hospital’s logistic system. Today is only a one level and two direction corridor, with many

UNITE

CORE

Children’s hospital is sepa-

Important part of our master

rated from the main part of

plan is a central core. At the mo-

the hospital by a loaded road

ment a vast amount of functions

which is the main city road

are put together. We suggest to

from airport to city centre.

concentrate all patient rooms and

Due to necessity for future

treatment in that part. This will

growth of hospital we offer

enclose wards from city and give

to unite main hospital’s block

them their own courtyard.

with a kid hospital’s block, thus to have a possibility for densification.

DEFRAGMENT SUS contains many functions: day treatment, research, emergency, etc. At the moment they are mixed with each other so there is no a particular order in it. Part of the proposal is a spatial defragmentation. We divide into different areas depending on functions they contain.

54

CONNECT Although

hospital

is

sur-

rounded by city, it’s not as well connected with it as it could be.

By clarifying main access ways and making more distinct facade we try to improve visual and physical

connection

hospital and city.

between

Since the hospital is so close to one

There is a clear centre area where

Creating the link with the Children’s

of Malmö’s most breathtaking parks, the

most of the facilities converge, having to-

hospital is a prevailing action for the de-

connection to this place is prevailing. A

day already the face of a main street. The

velopment of the Hospital. Efficient con-

main city road stands in the way on both,

intention is to create a pedestrian walk

nections and perceived link between them

so to get a fluid and non interrupted flow

with urban qualities that flows trough the

influences the users view, responding to

towards and from the park, we decided to

faces and entrances of the units. To avoid

the department as part of the complex,

create an underground passage. To avoid

a dull walk, the street will be accompa-

instead of being a segregated island, dis-

doing a dark anonymous tunnel, a slop-

nied by courtyards that will bring a fluent

connected from context. This is made by

ing plaza is proposed as a promenade to-

rhythm and will provide a prelude for the

creating a double south entrance that

wards the tunnel, giving light and public

entrances, giving quality and green out-

creates an underground link to the chil-

space also to the neighbour buildings.

door space to users.

dren’s hospital.

55

BUILDING 65

The existing Building

THE SITE_ Locate in the heart of the Hospital, but hidden away immersed in an internal park, the building now denies its surroundings. Turning around becomes a logical step, facing the existing nature and landscape.

The new axis looks to harvest the benefits of what is existing already on the site and also becoming a strategic point of further developments planed for the hospital, like strengthening the centre block, now built by old houses that fail to comply to the necessities of the hospital program.

56

57

58

59

FAN ROOM FAN ROOM

TECHNICAL ROOM

TECHNICAL ROOM

SIXTH FLOOR

TECHNICAL ROOM

STAFF AREA

DERMATOLOGY CONSULT AREA DERMATOLOGY TREATMENT AREA

OFFICES

FIFTH FLOOR

STAFF AREA OFFICES CONNECTION OPERATION FLOOR STAFF AREA PRE OPERATION WAITING AREA

VENTILATION OPERATION ROOM

OPERATION ROOMS

STAFF AREA

FOURTH FLOOR POST OPERATION UNIT

SERVICE AREA

STORAGE OPERATION ROOMS

STAFF AREA

SINGLE PATIENT ROOM

B U I L D I N G

P O R P O U S E S:

MULTIPLE PATIENT ROOM

OFFICES

_Enhance team communication THIRD FLOOR

MULTIPLE PATIENT ROOM

MULTIPLE PATIENT ROOM

OFFICES

OFFICES

STAFF AREA STAFF AREA

OFFICES

OFFICES

_Organize and clrify circulations. _Streamline patient flow

DOCTORS ROOM

_Improve waiting time and overall stay condition _Bring daylight inside the ward

RECEPTION ADMINISTRATION

SECOND FLOOR

SINGLE PATIENT ROOM

STAFF AREA

_Offer quality social space RECEPTION ADMINISTRATION OFFICES

LECTURE ROOM

_Provide a flexible comfortable room.

FIRST FLOOR

CONSULT

STAFF AREA

OFFICES TREATMENT ROOMS

ADMINISTRATION

AMBULATORY CONSULT

SERVICE AREA

GROUNDFLOOR

CONSULT RECEPTION ADMINISTRATION

OFFICES

AUDIOLOGY MEASSURING ROOMS

LABORATORIES

ARCHIVE

UNDERGROUND UNDERGROUND PASSAGE WAY

60

TECHNICAL ROOM

AXONOMETRIC ANALYSIS OF PATIENT FLOWS

SIXTH FLOOR

SIXTH FLOOR

FIFTH FLOOR

FIFTH FLOOR

FOURTH FLOOR

FOURTH FLOOR

THIRD FLOOR

THIRD FLOOR

SECOND FLOOR

SECOND FLOOR

FIRST FLOOR

FIRST FLOOR

GROUNDFLOOR

GROUNDFLOOR

AXONOMETRIC ANALYSIS OF VERTICAL CONNECTIONS

UNDERGROUND

PATIENT

UNDERGROUND

VERTICAL

With only one main access point lowered from

In the building structure we find a central and public con-

street level, makes it hard to find the place to enter the

nection that works as a distribution node for all three wings.

buildings. Once inside the space the elevators are the

though facing the same space, the volumes for elevators and

most important element. From a “distribution” space the

stairs are separated. Inside the building there is a service eleva-

entrances of the three buildings are labelled. In case of

tor and an emergency stair that connects all the floors.

transfer patients the underground corridor is used.

AXONOMETRIC ANALYSIS OF SERVICE FLOWS

SIXTH FLOOR

SIXTH FLOOR

FIFTH FLOOR

FIFTH FLOOR

FOURTH FLOOR

FOURTH FLOOR

THIRD FLOOR

THIRD FLOOR

SECOND FLOOR

SECOND FLOOR

FIRST FLOOR

FIRST FLOOR

GROUNDFLOOR

GROUNDFLOOR

AXONOMETRIC ANALYSIS OF STAFF FLOWS

UNDERGROUND

SERVICE

UNDERGROUND

STAFF

Service flow is a general underground corridor

Staff members are probably the ones with more flex-

that connects all the buildings, through nº 65 is the en-

ibility in flows, starting from various access points in different

trance for the adjacent buildings also. It has one vertical

levels, using mainly the public/main vertical connection Since

point inside the unit and one loading area outside the

their service area is spread through the different units and de-

same, making use of the public vertical circulation, which

partments, there is no main circulation pattern today.

creates a superposition of uses.

61

BUILDING 65 _BUILDING 65 REAL SITUATION: NG ROOM WORKS? The existing Room Dissecting building 65 FAMILY AREA

MALMÖ SUS _BUILDING 65

CLINICAL SUPPORT

Though there is a defined space for visitor, it lacks of flexibility in use, without giving the patient a real opportunity of use. The area becomes a well light niche but fails to provide a quality space for use.

Because of the high rates of updating and changes that the medical equipment requires it becomes a sort of collage of different typologies of elements, that enhance the confusion an disorientation of the patient and also making the medical staff’s work less clear, having to recognize between the elements before taking action, which translates in time loss.

PATIENT UTILITIES Placed in a movable unit, it blends with the clinical equipment creating confusion in use and in approach. The patient doesn’t make it his and that is translated in a sense of being out of place.

HOW DOES THE EXISTING ROOM WORKS?

THE ROOM _The views to the outside, that becomes

obstructed by the irregular shape of the room, are far from The views to the that becomes ideal. The fact of the small outside balcony, thatoutside, becomes more

THE ROOM _

obstructed thea clear irregular shape ofadds the elements room, arethat far from an obstacle for lightbyand view, it also ideal.

The fact of the small outside balcony, that becomes ruin the view even more. Its clear from the pictures that the more

ACILITIES

o the rest of the hyoutside the room, level of privacy. Exst vulnerable state, aid for the path the personal sector.

omes obstructed by the r from ideal. The fact of comes more an obstacle adds elements that ruin m the pictures that the or light, and none when d. s, rails, volumes create m, tried to be fixed by an ing the task. Colour use g the areas or informing an area for reading and able view and becomes

S

E

S

:

e view

dical information, create room. Visible for the

possibility for longer ac-

an obstacle for light and a clear view, it also adds elements that inner bed doesn’t get much view or light, and none when the ruin the view even more. Its clear from the pictures that the other patient’s curtain is closed. inner bed doesn’t get much view or light, and none when the The multiplicity of elements, cables, rails, volumes crePThe APatient T Idoesn’t E N T aZdefined O Narea,E other patient’s curtain is closed. ate a perceptual chaos inside the room, tried have to be fixed by an blending with the public and technical The multiplicity of elements, cables, zones, creating a sensation ofrails, rootless- volumes creuniform colour, but not accomplishing the Colour use is ness. In the endtask. nor the whole room is nor a defined space really beate a perceptual chaos inside “owned” the room, tried to be fixed by an longs to the patient. not used in its potential, clarifying the areas or informing the uniform colour, but not accomplishing the task. Colour use is patient. Even though there is an area for reading and visitors is not used in its potential, clarifying the areas or informing the the best light an improvable view and becomes small for both patient. Even though there is an area for reading and visitors is patients. the best light an improvable view and becomes small for both patients.

PATIENT

FACILITIES

Not only the shower but also the rest of the hygienic facilities are placed outside the room, striping the patient from any level of privacy. Exposing the sick in their most vulnerable state, and requesting commonly aid for the path since it requires to go out the personal sector.

The views to the outside, that becomes obstructed by the irregular shape of the room, are far from ideal. The fact of the small outside balcony, that becomes more an obstacle for light and a clear view, it also adds elements that ruin the view even more. Its clear from the pictures that the inner bed doesn’t get much view or light, and none when the other patient’s curtain is closed.

The multiplicity of elements, cables, rails, volumes create a perceptual chaos inside the room, tried to be fixed by an uniform colour, but not accomplishing the task. Colour use is not used in its potential, clarifying the areas or informing the patient. Even though there is an area for reading and visitors is the best light an improbable view and becomes small for both patients.

the patient.

P

U

R

P

O

U

S

E

S

:

_Increase daylight levels and frame view _Private but flexible rooms _Assign space for digital open medical information, creating and information section in the room. Visible for the patient. _Improve family Zone, giving the possibility for longer accommodation and over stay. _Design an obstacle free path for the patient.

62 Master Thesis Project _ Healing Hospital _ Malmö SUS

CLINICAL SUPPORT Because of the high rates of updating and changes that the medical equipment requires it becomes a sort of collage of different typologies of elements, that enhance the confusion an disorientation of the patient and also making the medical staff’s work less clear, having to recognize between the elements before taking action, which translates in time loss.

PATIENT UTILITIES Placed in a movable unit, it blends with the clinical equipment creating confusion in use and in approach. The patient doesn’t make it his and that is translated in a sense of being out of place.

MALMÖ SUS _BUILDING 65 HOW DOES THE EXISTING ROOM WORKS?

FAMILY AREA

CLINICAL SUPPORT MALMÖ SUS _BUILDING 65

Though there is a defined space for visitor, it lacks of flexibility in use, without giving the patient a real opportunity of use. The area becomes a well light niche but fails to provide a quality space for use.

HOW DOES THE EXISTING ROOM WORKS?

FAMILY AREA Though there is a defined space for visitor, it lacks of flexibility in use, without giving the patient a real opportunity of use. The area becomes a well light niche but fails to provide a quality space for use.

Because of the high rates of updating and changes that the medical equipment requires it becomes a sort of collage of different typologies of elements, that enhance the confusion an disorientation of the patient and also making the medical staff’s work less clear, having to recognize between the elements before taking action, which translates in time loss.

PATIENT UTILITIES Placed in a movable unit, it blends with the clinical equipment creating confusion in use and in approach. The patient doesn’t make it his and that is translated in a sense of being out of place.

FAMILY AREA

CLINICAL SUPPORT

R

P A T I E N TFACILITIES ZONE PATIENT

doesn’tbut have a defined NotThe onlyPatient the shower also the restarea, of the hyblending with are the public technical gienic facilities placed and outside the room, zones,the creating sensation of rootlessstriping patienta from any level of privacy. Exness.the In the whole room is state, posing sickend in nor theirthe most vulnerable nor a commonly defined space be- path and“owned” requesting aid really for the longs the patient. since it to requires to go out the personal sector.

Because of the high rates of updating and changes that the medical equipment requires it becomes a sort of collage of different typologies of elements, that enhance the confusion an disorientation of the patient and also making the medical staff’s work less clear, having to recognize between the elements before taking action, which translates in time loss.

O

O

M

PATIENT UTILITIES Placed in a movable unit, it blends with the clinical equipment creating confusion in use and in approach. The patient doesn’t make it his and that is translated in a sense of being out of place.

Though there is a defined space for visitor, it lacks of flexibility in use, without giving the patient a real opportunity of use. The area becomes a well light niche but fails to provide a quality space for use.

P

U

R

P

O

U

S

E

PATIENT ZONE

S:

The Patient doesn’t have a defined area, blending with the public and technical zones, creating a sensation of rootlessness. In the end nor the whole room is “owned” nor a defined space really belongs to the patient.

_Increase daylight levels and frame view _Private but flexible rooms

The views to the outside, that becomes obstructed by the irregular shape of the room, are far from ideal. The fact of the small outside balcony, that becomes more an obstacle for light and a clear view, it also adds elements that ruin the view even more. Its clear from the pictures that the inner bed doesn’t get much view or light, and none when the other patient’s curtain is closed.

The multiplicity of elements, cables, rails, volumes create a perceptual chaos inside the room, tried to be fixed by an onlyaccomplishing the shower but alsothe the rest of the hyuniform colour, butNot not task.

Colour use gienic facilities are placed outside the room, is not used in its potential, clarifying the areas or informing striping the patient from any level of privacy. Exthe patient. Even though there is an area for reading and posing the sick in their most vulnerable state, visitors is the best and light an improbable view becomes requesting commonly aid for and the path since it requires to go out the personal sector. small for both patients.

PATIENT

_Assign space for digital open medical information, creating and information section in the room. Visible for the patient. _Improve family Zone, giving the possibility for longer accommodation and P A T I E N Tover Z Ostay.

NE

FACILITIES

The Patient doesn’t have a defined area, blending with the public and technical zones, creating a sensation of rootlessness. In the end nor the whole room is “owned” nor a defined space really belongs to the patient.

_Design an obstacle free path for the patient.

The views to the outside, that becomes obstructed by the irregular shape of the room, are far from ideal. The fact of the small outside balcony, that becomes more an obstacle for light and a clear view, it also adds elements that ruin the view even more. Its clear from the pictures that the inner bed doesn’t get and much viewview or light, and none when _Increase daylight levels frame the other patient’s curtain is closed. _Private but flexibleofrooms The multiplicity elements, cables, rails, volumes create a perceptual chaos inside the room, information, tried to be fixed by an _Assign space for digital open medical creatuniform colour, butsection not accomplishing theVisible task. Colour ing and information in the room. for theuse is not used in its potential, clarifying the areas or informing patient. the patient. Even though there is an area for reading and _Improve giving possibility for longer acvisitorsfamily is the Zone, best light anthe improbable view and becomes commodation and over stay. small for both patients.

P

U

R

P

O

U

S

E

S

:

_Design an obstacle free path for the patient.

P

U

R

P

O

U

S

E

S

:

63

CLINIC

Because of dating and chan equipment req sort of collage o of elements, tha sion an disorien and also making work less clear between the ele action, which tra

PATIEN

Placed in blends with the creating confu in approach. T make it his an in a sence of

PATIENT

FACILITIES

Not only the shower but also the rest of the hygienic facilities are placed outside the room, striping the patient from any level of privacy. Exposing the sick in their most vulnerable state, and requesting commonly aid for the path since it requires to go out the personal sector.

64

CAL SUPPORT

f the high rates of upnges that the medical quires it becomes a of different typologies at enhance the confuntation of the patient g the medical staff’s r, having to recognize ements before taking anslates in time loss.

FAMILY AREA

Though there is a defined space for visitor, it lacks of flexibility in use, without giving the patient a real opportunity of use.

The area becomes a well light niche but fails to provide a quality space for use.

NT UTILITIES

a movable unit, it e clinical equipment usion in use and The patient doesn’t nd that is translated being out of place.

PATIENT ZONE

The Patient doesn’t have a defined area, blending with the public and technical zones, creating a sensation of rootlessness. In the end nor the whole room is “owned” nor a defined space really belongs to the patient.

65

NEW BUILDING 65

Strategies to Upcycle the structure

By re organizing and extending outside the circulation spaces, the total area grows but most important it shifts its role from an administrative building to a care unit. Housing enough wards makes it coherent and underlines its character, leaving more administrative functions on a more secondary position.

PLAN 07

STAFF

PLAN 06

TECHNICAL

PLAN 05

STAFF

PLAN 04

OPERATION

PLAN 03

WARD

PLAN 02

WARD

PLAN 01

WARD

PLAN 00

ACCESS _ DAY CARE

PLAN -1 66

UNDERGROUND SYSTEM

67

NEW BUILDING 65

Strategies to Upcycle the structure

1

CONNECT_ Create a link to the sorroundings

through

strengthening ties with the existing landscape. Leveraging the existing park as an extension of the building in a visual and physical sphere.

68

oundties Lev-

an ex-

visual

s that

erous

ayout.

places

within

d the

giving

e and

69

NEW BUILDING 65

Strategies to Upcycle the structure

2

LIGHT_ By breaking the massive volume through light chambers that run across the existing structure, allowing light and more generous spaces to ow inside the layout. Open the facade in strategic places to ensure

day perception

within the building.

70

e volthat

cture,

erous

ayout.

places

within

71

NEW BUILDING 65

Strategies to Upcycle the structure

3

TURN_ Create trance

a

toward

new the

enrich-

est park in the hospital, projecting the circulation spaces to the green oasis.

Extend the axis towards the courtyard giving clarity to the building structure and functions, and allowing more generous organizing spaces.

72

e to-

hospi-

spac-

d the

giving

e and gen-

73

74

75

B enaL GVA

radio therapy

daycare

81

Consult

71 61

daycare

Consult

51 41 31 21 11

Room Operation

01 9 8

Room Operation

Room Rinsing

Room Operation

Room Operation

Room Rinsing

Room Operation

Room Operation

A Room Lab

W.C.

Area Supply Office

81

Room Data

Room Operation

i

Pre-Post Operation 1

Office

Consult

91 2 81

8

Office

3 71 4

Office

Office

Office

Office

Room Lab

61

51

daycare

daycare

6 41 7 31

9

21

01

11

8

B

9

21

01

11

5

PLAN -1

PLAN 04

83,97 4,75

28,55 4,00

4,00

4,00

7,60 4,00

4,00

4,00

20,90

8,00

4,00

4,00

4,00

14,16 4,00

4,70

8,58

8,02 5,48

8,07

Rinsing Room

Consult Room

Testing Room

Diagnose Room

File Room

Nurse Station

Kiosk-Cafe

Rinsing Room

Team Station 2

14,14

Team Station 3 Team Station 4

Team Station 1

Storage Room

W.C.

Reception Desk

Supply Area

6,71

11,11

W.C.

Staff Kitchen

26,14

5,29

4,00

PLAN 00 76

Room Lab

R.W.C

8

Consult

7

Lockers Storage

6

Room Operation

5

Room Storage

4

6

3

Room Workshop

5

41 7

2

1

Office

51

31

Room Lab

W.C

9

8

7

6

i

5

4 61

4

3 71

3

2

1

2 81

Office

11 01

9

1 91

Office

Room Conference

21

61

81

31

41

51

71

Desk Reception

21

Room Storage

Room Storage

61

Room Storage

31

Storage Sterile

Corridor

41

Room Sterile

Office Kontor

11 01

51

Storage Sterile

A

71

3

2

1

6

5

4

7

A

Room Lab

Ro La

B

B

B

SECTION BB’

technical Room Technical

Room Cleaners

TECHNICAL FLOOR

A

Room Conference

A

A

Room Conference 81

Desk Reception

Cafeteria Staff

21

Room Storage

61

Technology Operating

31

Room Storage

41

Room Lab

51

Room Storage

A

71

Room Lab

A

W.C.

W.C.

11

W.C.

01 9

8

7

6

5

4

i

3

Waste Room

2

1

1

1

91

91 2

81

2

81

81

3

3

71

3

71

71

4

4

61

4

61

61

5

5

6 41

7

7

31

31

9

21

B

01

8

9

21

8

B

9

21

01

51 6

41

B

11

8

01

7 31

5

51

technical

6 41

11

51

11

Office

PLAN 05

PLAN 06

PLAN 07

12

daycare

9

Office

11

Office

10

Room Lab

1

91 2

Room Lab

8 13 14 15 16 17

i

18 19

7

6

5

4

3

2

1

Head Nurse

8

7

6

5

4

3

2

1

9 10

W.C.

Staff Kitchen

daycare

Team Station 3

12

14

13

16

15

18

17

11

oom ab

SECTION AA’

Rinsing Room

Testing Room

Diagnose Room

File Room

Nurse Station

Patient Kitchen

Testing Room

Rinsing Room

Team Station 4

Team Station 2

Team Station 1

Storage Room

Reception Desk

Supply Area

W.C.

1 Patient Bedroom

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

4,00

PLAN 01-03 77

STATISTICS

+

OLD PATIENT

MEDICAL

SOCIAL

541,6 M2

350,2 M2

84 M2

NEW PATIENT

MEDICAL SOCIAL

544,8 M2

290,2 M2 155,1 M2

+ 67% BEDS

22,7 M2 14,6 M2

78

+

+

55,4% M2

57,1%

0,7

X PATIENT

WC X PATIENT

SOUTHERN FACADE _ MAIN ENTRANCE

Create a more patient oriented ward, upgrading its features: more room floor, more

SCALE 1:250

EXISTING ENVELOPE

sanitary services, more beds.

EXISTING ST

BALCONY

RUCTURE

EXTENSIO

N

Overtake the existing and unused balcony to extend the patient’s usable area.

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NEW WARD

How can the Existing Layout be Improved?

MALMĂ– SUS _PROPOSED WARD HOW CAN THE EXISTING LAYOUT BE IMPROVED?

WARD FLOOR

PERSPECTIVE PLAN

INTERNAL FLOW_

CORRIDOR SPACE_ Though repetition exits due to the room module, the core is the one that creates and defines the opposing space. By fluctuation in depth and interruptions in the front the space becomes more fluid and give possibility for more.

By opening up the core in wide flow exchangers the circulation avoids the rigid loop and is replace by multiple choice paths that differ in lengths and spatial characteristics.

CONTROL VIEW_

Replace the unique centered control point with multiple cross facing check points for a more efficient performance. The areas allow to create functional teams to overlook and care smaller groups of patients.

The Existing layout shows a confusing distribution of functions, and more troubling, it gives no signs for inner orientation or connection to the outside. The intention for the new layout is to create a simple plan, that would be easy to read, both for patients and staff. One guiding intention was to free the view before of the corridor, making it always end in and outside clear view, before giving the user a permanent sense of orientation. Besides opening the ends, the layout breaks the length through spacious openings that cut trough the whole volume, crating circulation nodes. after after

80

before

after

MALMÖ SUS _PROPOSED WARD HOW CAN THE EXISTING LAYOUT BE IMPROVED?

WARD FLOOR

PERSPECTIVE PLAN

INTERNAL FLOW_

CORRIDOR SPACE_ Though repetition exits due to the room module, the core is the one that creates and defines the opposing space. By fluctuation in depth and interruptions in the front the space becomes more fluid and give possibility for more.

before

By opening up the core in wide flow exchangers the circulation avoids the rigid loop and is replace by multiple choice paths that differ in lengths and spatial characteristics.

CONTROL VIEW_

Replace the unique centered control point with multiple cross facing check points for a more efficient performance. The areas allow to create functional teams to overlook and care smaller groups of patients.

before

before

after

after

after

12

Master Thesis Project _ Healing Hospital _ Malmö SUS

Student _ María Soledad Larraín Salinas

Tutors _ Walter Unterrainer _ Juri Soolep

LSAP _ UMA

H 81

READING ROOM_ Though social spaces are needed, variety is also needed.

For creating a wider range of options a more remote space gives the chance of a quieter and isolated instance for practices like reading.

1 NURSE STATION_ Placed in the heart of the ward, the main station has not only direct control over the social spaces, but also gets view and light from the exterior. Besides it sits in front of the kitchen for close control.

2 SOCIAL SPACE_ Commonly referred as the “day room� the space now opens up completely, both inside and outside to create a more connected and fluid space.

Also gives the chance of the use of a protected balcony.

3 RECEPTION DESK_ With a more administrative role, this acts as a control point for the access and circulation to and inside the ward.

Also the existing of and information element gives guidance for visitors and patients.

4 82

1 2 3

3

4

CONNECT_

WARD FLOOR PERSPECTIVE PLAN

Create a link to the surroundings through strengthening ties with the existing landscape. Leveraging the existing park as an extension of the building in a visual and physical sphere.

83

4

culation to and inside the ward. Also the existing of and information element gives guidance for visitors and patients.

NEW ROOM

What makes it a better room?

01 ROOM SIZE _

Though the structural grid is kept, the shared bed becomes a single patient room, giving the patient more personal space and also guaranteed.

02 VIEW _

Through a deep window, the view is framed, becoming clear and clean. The view becomes a understandable and strong element inside the room’s layout.

03 NATURE_ Plus the direct view

from bed, the patient has the possibility of multiple spaces with different levels of relation to the exterior, beside of nature inspired graphics.

84

WARD FLOOR

PERSPECTIVE PLAN

07

04 PERSONAL SPACE_ By means

HYGIENIC SUPPORT_

of single rooms the patient doesn’t only gets his needed privacy, but also contributes to host medical interaction in the environment.

many research studies hand washing for part of staff, becomes one of most relevant factors to duce contact infections.

05

08

FAMILY ZONE_ Creating a safe

VISIBILITY_

In the the the re-

environment benefits the patient’s recovery and for that family support is essential.

To promote this practice, a welcoming space is needed.

The chance to check from the corridor gives the nurses control over the patient and also gives comfort to patient with high anxiety levels, without disturbing.

06

09

HYGIENIC INDEPENDENCY_

LIGHTING_

Individual bathrooms become a necessity on a modern hospital, giving the advantage of liberated use and reducing patient stress.

Unique lighting settings should be provided to accommodate various tasks that might take place in a patient room and give control.

Master Thesis Project _ Healing Hospital _ Malmö SUS

Student _ María Soledad Larraín Salinas

85

NEW ROOM

How can a new room be deямБned?

IVA

CY

LIC

B PU

SEMI PROVATE

PRIVATE

PR

VE

R CU

86

PATIENT FACILITIES_

CLINICAL SUPPORT ZONE_

PATIENT ZONE_ PATIENT UTILITIES_

FAMILY SUPPORT ZONE_

87

NEW ROOM The New Layout

3,28

1,38

Existing Structure Service Shaft View and Control point of Patients

3,08

Handicaped Accesible with 80 cm to the wall and 1 meter to the shower

Unique Assisted translucent door 1,28

Clinical Support Unit located in main staff path

Patien Area 8.41m2

TV and entertainmet Set

Patien Bed 110cmx210cm

Family Support Zone

Wooden floor Patient’s Closet

2,40

Foldable bed hidden in the wall Sitting/ Bed for visitors

Frame also used for sitting

Floor to Ceiling Window

0,15 0,62

1,66 1,19

0,15

2,05

0,15

2,17 4,00

88

0,60 0,36

3,39 3,51 4,00

0,15 0,15

NEW ROOM

The Room Profile

FAMILY SUPPORT ZONE_ PATIENT ZONE_ PUBLIC SPACE_

PATIENT FACILITIES_

CLINICAL SUPPORT ZONE_

Flow Diagrams

TASK ANALYSIS_ Nursing Care

TASK ANALYSIS_ Bathroom Use

TASK ANALYSIS_ Visitors

TASK ANALYSIS_ Patient Code 89

TV and entertainmet Set

Patien Bed 110cmx210cm

Wooden floor

Family Support Zone Patient’s Closet

Frame also used for sitting

Floor to Ceiling Window

Window and their Impact 0,15

0,62

2,40

NEW ROOM

Foldable bed hidden in the wall Sitting/ Bed for visitors

1,66

1,19

0,15

2,05

0,15

2,17

4,00

0,60 0,36

3,39 3,51

0,15 0,15

4,00

Openable window

FIxed _ framed Window

FIxed _ no frame Window

ROOM FACADE STUDY

90

Daylight Conditions EXISTING ROOM

PROPOSED ROOM TYPE 1

PROPOSED ROOM TYPE 2

88,7 lux (At bed space)

230,3 lux (At bed space)

210,6 lux (At bed space)

91

NEW ROOM Room Elements

To create a more comfortable family area.

Also the reflectance of the material works as an amplifier of daylight, filling the room with it. It also becomes a viewing element from the bedside, giving a sense of extra quality.

The volume of the wards is configured by a wooden facade that searches to break the hardness of the typical hospital block existing. The material sends a message of comfort and warmth before the aptient even steps into the building.

By creating a frame the patient is aware of the view to the outside, and also the window becomes an extra feature in the room. The possibility of using the space by the openings give the patient and incentive to move and get out of the bed.

Coloured ceramics on the sink wall, to create a lively environment and break with the sterile character of the space. It also contains the water spill from the sink and frames the patient’s mirror.

Natural and durable product. One important factor is that is easy to clean and maintain; and provides a safe walking surface. The same material will flow from the room to the bathroom to break the rooms limits.

92

93

94

95

CONCLUSIONS Lessons and reflections

96

The project started as an exercise to test the possibilities of re-use on an existing structure. Under used buildings are everywhere and are affecting the city’s density, and what is more troubling they are pushing the industry to build new, that as it was shown in the project is not always needed.

From the lessons towards re-using occupied frames is possible to extract the necessity of clear planing and explicit strategies. Committing all the parts to a goal is essential, specially in a project like a hospital, that tends to branch out, making it really easy for it to loose the north, or in this case: the south.

This strategies are not given from above, but involvement of the actors is crucial. Interdisciplinary and user oriented work was a corner stone of this work, and it appears to be an obligatory element for successful endeavours. The tendency as architects to fall into wishful thinking and then “landing” projects, is only translated in an awkward marriage between the original concept and more pragmatic requirements from the actors that will actually occupy the space. This thesis only reassures the thought that it must not be forgotten that architects create space for others, and should have it in mind and involve the different actors in the process for a more fruitful result.

Though small changes is the only thing needed in some circumstances, sometimes, like in this example, a mayor renovation is deserved. Where the building rises up to its potential, housing more rooms and decompressing the need in the overall hospital. Inside the ward functional and modular rooms are a necessity, but is important not to fall into repetition, but instead create spaces that walk away from the “machine” like approach. With small but consistent actions: like the pursuit of light and creating a clear interior layout the ward can become a much healthier and efficient place to both work and recover. Patient centred care has a good intention, but it was shown in this research that both patient and staff have to be in a better planed environment to be able to create a heathier overall milieu.

This exercise as it was shown, is not about taking so radical solutions, but more strong and reality based guidelines to achieve the goal of up grading the existing spaces and functions.

The hospital is a very complex structure, and probably I just managed to scratch the surface and expose some of the issues at hand. Highly wived projects as this one need to have, with more reason, a leading idea, a principle to which the parts fall into and commit, only this will ensure a favourable result that will translate into a healthier hospital.

97

REFERENCES

98

BIBLIOGRAPHY _ Bergman, Bo, Duncan Neuhauser and Lloyd Provost. Five main processes in healthcare: a citizen perspective. BMJ Group, 2012. _ Foucault, Michel. The Birth of the Clinic. London: Routledge, 2003. _ Francis, Susan, Rosemary Glanville, Ann Noble and Peter Scher. 50 years of Ideas in health care buildings. London: Nuffield Trust, 1999. _ Frampton, Susan and Patrick Charmel eds. Putting Patients First: Best Practices in PatientCentered Care. San Francisco: Jossey Bass, 2009. _ Meuser, Philipp and Christoph Schirmer. New Hospital Building in Germany. Volume 1: General Hospitals and Health Centres. Page One Publishing Private, 2007. _ NHS Estates. Ward layouts with single rooms and space for flexibility. Crown, 2005. _ Ulrich, Beck. The Brave New World of Work. Oxford: Polity Press, 2000. _ Ulrich, Roger. Effects of Healthcare Environmental Design on Medical Outcomes. Article Design & Health, 2001. _Wagenaar, Cor, ed. The Architecture of Hospitals. Rotterdam: NAi Publishers, 2006.

ON LINE REFERENCES World Health Organization

www.who.int/en

Edelman’s Health Barometer www.healthbarometer.edelman.com The Center of Health Design

www.healthdesign.org

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Master Thesis Project by María Soledad Larraín Salinas Healing Hospital: Upcycling the old for a healthier now.

Examiner: Michael Eden Professor: Walter Unterrainer External Supervisors: Juri Soolep _ Peter Kjaer.

Umeå Universitet _ UMA School of Architecture LSAP Laboratory for Sustainable Architectural Production Master Program 2010-2012

101