Hospitals: A Design Manual 9783035611250, 9783038214755

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Hospitals — A Design Manual

A Design Manual

Hospitals Cor Wagenaar Noor Mens Guru Manja Colette Niemeijer Tom Guthknecht Contributions by Giuseppe Lacanna Peter Luscuere

Birkhäuser Basel

We would like to thank the organizers of the ‘Building the Future of Health’ conference, www.btfoh.eu, for their kind support of this publication.

Layout and cover design Jenna Gesse, Berlin Graphic design concept of ‘Design Manual’ series Oliver Kleinschmidt, Berlin Cover Akershus University Hospital, Oslo, C. F. Møller Architects; photo: Torben Ekserod Frontispiece Surgical Clinic La Croix-Rousse, Lyon, Atelier Christian de Portzamparc; photo: Erick Saillet Concept Cor Wagenaar, Noor Mens Project texts Noor Mens, Cor Wagenaar Copy-editor Harvey L. Mendelsohn, Cambridge, Massachusetts Editorial supervision Ria Stein, Berlin Production Katja Jaeger, Amelie Solbrig, Berlin Lithography bildpunkt Druckvorstufen GmbH, Berlin Paper BVS matt, 150 g/m2 Printing Medialis Offsetdruck GmbH, Berlin

Library of Congress Cataloging-in-Publication data A CIP catalog record for this book has been applied for at the Library of Congress. Bibliographic information published by the German National Library. The German National Library lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available on the Internet at http://dnb.ddb.de. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in databases. For any kind of use, permission of the copyright owner must be obtained. This book is also available as an e-book (ISBN PDF 978-3-0356-1125-0; ISBN EPUB 978-3-0356-1126-7).

© 2018 Birkhäuser Verlag GmbH, Basel P.O. Box 44, 4009 Basel, Switzerland Part of Walter de Gruyter GmbH, Berlin/Boston Printed on acid-free paper produced from chlorine-free pulp. TCF ∞ Printed in Germany ISBN 978-3-03821-473-1 987654321 www.birkhauser.com

Principles of the Hospital Building 8 Preface Cor Wagenaar, Noor Mens 9 Introduction Cor Wagenaar, Noor Mens

DEFINING THE HOSPITAL OF TOMORROW

DESIGNING HOSPITALS

PUBLIC SPACES

TREATMENT AREAS

12 Paradigm Change? The Perspective of the Patient Cor Wagenaar, Noor Mens

23 Distribution of Healthcare Facilities: Centralization, Decentralization and the Network Hospital Guru Manja, Colette Niemeijer, Cor Wagenaar

52 Zoning and Traffic System Tom Guthknecht, Peter Luscuere, Guru Manja, Colette Niemeijer, Cor Wagenaar

67 Planning: an Integral Approach Tom Guthknecht

15 Healthcare as a Public Service Cor Wagenaar, Noor Mens 19 The Business Case for Hospitals Guru Manja, Colette Niemeijer 22 Changing Healthcare Needs Cor Wagenaar, Noor Mens

27 The Design of Hospitals: Care Pathways Guru Manja, Colette Niemeijer, Cor Wagenaar 32 Processes and Spaces: the Example of the Maternity Department Guru Manja, Colette Niemeijer, Cor Wagenaar 37 Evidence-Based Design for Healing Environments Cor Wagenaar 42 The Building Type and its Emergence Noor Mens

58 Arrival and Entrance Noor Mens

69 Outpatient Department Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar

61 Public Spaces in and Around the Hospital: Streets, Squares, Patios, Waiting Areas, Healing Gardens Giuseppe Lacanna, Cor Wagenaar

75 Inpatient Wards Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar

65 Wayfinding: Signage and Orientation Systems Noor Mens

83 Diagnostic Imaging Tom Guthknecht, Guru Manja, Cor Wagenaar 85 Operating Theater and Recovery Area Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar 100 Intensive Care Unit Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar 108 Emergency Department Tom Guthknecht, Guru Manja, Colette Niemeijer, Cor Wagenaar 111 Laboratory Department Tom Guthknecht

Selection of Projects GENERAL HOSPITALS

CHILDREN’S HOSPITALS

UNIVERSITY HOSPITALS

188 Center for Surgical Medicine University Hospital Düsseldorf Düsseldorf, Germany Heinle, Wischer und Partner

118 Circle Bath Bath, UK Foster + Partners

140 Hôpital Riviera-Chablais Rennaz, Switzerland Groupe-6; GD architectes

160 Nemours Children’s Hospital Orlando, Florida, USA Stanley Beaman & Sears

122 Butaro District Hospital Butaro, Rwanda MASS Design Group

142 Medisch Spectrum Twente Enschede, the Netherlands IAA Architecten

164 Randall Children’s Hospital at Legacy Emanuel Portland, Oregon, USA ZGF Architects

124 Private Hospital Villeneuve d’Ascq Lille, France Jean-Philippe Pargade Architectes

148 Rey Juan Carlos Hospital Madrid, Spain Rafael de La-Hoz

128 Extension Kolding Hospital Kolding, Denmark Schmidt Hammer Lassen Architects 130 AZ Groeninge Kortrijk, Belgium Baumschlager Eberle Architekten 134 Zaans Medisch Centrum Zaandam, the Netherlands Mecanoo

152 Meander Medisch Centrum Amersfoort, the Netherlands Atelier PRO architekten 156 Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates HDR

168 Juliana Children’s Hospital The Hague, the Netherlands MVSA Architects 172 Mother-Child and Surgical Center Kaiser-Franz-Josef-Spital Vienna, Austria Nickl & Partner Architekten 176 Ann & Robert H. Lurie Children’s Hospital Chicago, Illinois, USA ZGF Architects 182 Royal Children’s Hospital Melbourne, Australia Billard Leece Partnership; Bates Smart

192 St. Olav’s Hospital Trondheim, Norway Nordic – Office of Architecture; Ratio Arkitekter 196 Akershus University Hospital Oslo, Norway C. F. Møller Architects 200 Reconstruction of the Johann Wolfgang Goethe University Hospital Frankfurt am Main, Germany Nickl & Partner Architekten 204 Erasmus MC Hospital and Education Center Rotterdam, the Netherlands EGM architects; KAAN Architecten

SPECIALIZED HOSPITALS

OUTPATIENT CLINICS AND HEALTH CENTERS

REHABILITATION AND SUPPORT CLINICS

APPENDIX

210 Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, Nevada, USA Frank Gehry

232 Ruukki Health Clinic Ruukki, Finland alt Arkkitehdit; Architecture Office Karsikas

248 Maggie’s Centre West London London, UK Rogers Stirk Harbour + Partners

268 The Authors

212 Surgical Clinic La Croix-Rousse Lyon, France Atelier Christian de Portzamparc

234 Municipal Healthcare Centers San Blas, Usera, Villaverde Madrid, Spain Estudio Entresitio

216 Milstein Family Heart Center NewYork-Presbyterian Hospital New York, New York, USA Pei Cobb Freed & Partners

238 UCLA Outpatient Surgery and Medical Office Building Santa Monica, California, USA Michael W. Folonis Architects

220 National Center for Tumor Diseases Heidelberg, Germany Behnisch Architekten 224 Institut Imagine Paris, France Ateliers Jean Nouvel; Valero Gadan Architectes 228 Cancer Centre at Guy’s London, UK Rogers Stirk Harbour + Partners

240 New QEII Hospital Welwyn Garden City, UK Penoyre & Prasad 242 Outpatient Clinic Hospital-Asilo of Granollers Granollers, Spain Pinearq

250 Maggie’s Centre Gartnavel Glasgow, UK OMA 252 Gheskio Cholera Treatment Center Port-au-Prince, Haiti MASS Design Group 254 Cancer Counseling Center Livsrum, Denmark EFFEKT Arkitekter 258 Healthcare Center for Cancer Patients Copenhagen, Denmark Nord Architects 262 Rehabilitation Center Groot Klimmendaal Arnhem, the Netherlands Koen van Velsen Architects 266 Anti-Aging Life Center Chaum Seoul, South Korea KMD Architects

268 Index of Places 270 Index of Names 271 Illustration Credits

Preface Hospitals — A Design Manual is a book for architects, hospital administrators and planners, medical specialists and policy makers about the latest trends in hospital architecture and it aspires to be a tool for change. As used in this manual, the term ‘design’ encompasses more than spatial configuration, the use of materials, color, windows, doors and furniture. The authors present the hospital as a composition of components, each of which can be designed in various ways. We offer a range of choices, many of which are determined by programming decisions. Weighing various options is an essential part of the architect’s task in designing a hospital. The publication’s focus is on people and processes rather than on medicine and technology. Caring for people and optimizing the processes they undergo are constant concerns in hospitals, no matter how quickly and fundamentally medicine and technology change. In hospital design, there are no standard solutions. Each hospital represents a unique combination of design decisions that is determined by its specific context, including the characteristics of the population it serves, demographic trends, healthcare systems, economic realities, etc. If the reader comes away with a heightened awareness of the many questions architects and decision makers have to consider, then this book will have served its purpose. The projects documented here have been selected because they represent fundamental trends. Revolutions in healthcare architecture are always slow – paradigm changes take time to materialize. Some of the trends illustrated by the case studies have been underway for quite some time, others are more recent, but both testify to the gradual emergence of new hospital landscapes. The manual is the result of teamwork. Tom Guthknecht, an internationally renowned healthcare architect, theoretician and consultant, helped define the main principles of hospital planning as well as identify current trends and challenges in designing specific functional components. Kirk Hamilton, a prominent healthcare architect, is also an expert on evidence-based design; his input focused on the use of science in architecture. Peter Luscuere, a leading professional in hospital construction, general layout models and clean air technology, contributed to the parts of the book dealing with these issues. Guru Manja and Colette Niemeijer, who specialize in the reconceptualization of the hospital from the patient’s perspective and in hospital programming, were responsible for describing the close link between patients’ needs, the program, logistics and business matters, on the one hand, and architecture and distribution models, on the other. Laura Bulau, Marien Kleizen and Kees de Wit at CEANconsulting produced all the graphs and diagrams. Many people have helped in making this book happen — we mention only two of them. We thank Ria Stein for staying with us when for a number of reasons the project came to a complete standstill — this manual is the result of its renaissance in the spring of 2014. We are particularly grateful to Harvey Mendelsohn with whom we have worked on many projects for many years; his editorial skills were indispensable. Cor Wagenaar and Noor Mens

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Introduction Only a decade ago, architects and critics considered hospital architecture to be a field ‘lagging behind the most inventive and progressive developments in the art and science of architecture, and indeed losing the commitment and skill required in the making of places that mean something to people’.1 Since then the situation has changed completely. Hospitals are back in the frontlines of architecture. The world’s leading designers have discovered that this building type offers fundamental, indeed unique design challenges. Absorbing the latest findings in science, psychology, medical technology and the digital revolution, exploring the urban surroundings as a framework for integration and reflecting major economic trends and, most notably, the transfer of responsibility to the end user, hospitals address fundamental aspects of human life in ways no other buildings do. Few other institutions have such a direct impact on the quality of life of the people who rely on their services. Sometimes the stakes are even higher: whether a patient lives or dies may depend on the way a hospital performs. This book outlines how architecture can help hospitals increase the efficiency of the medical processes they house, while simultaneously improving financial performance and, most importantly, providing patients with better care. Since their architecture directly affects how hospitals function, we believe that the architect’s role goes beyond the realm of design in the strict sense. Architects involved in planning a hospital must address a host of issues: accommodating the flows of staff, patients and their visitors, balancing efficient use of facilities with the need to meet unpredictable peaks in demand and ensuring sufficient flexibility in the design to accommodate constantly evolving technology, to name but a few. They should be capable of assessing the impact of design solutions on the efficiency of medical processes and, therefore, of expanding the scope of their work to include the functional program: logistics, public spaces, wayfinding, patient transfers, the balance between single- and multiple-patient rooms, ergonomics, etc. As the CEO of an American hospital stated, architects ‘…should want more control and be a more integral part of the medical team’.2 If they accept the reduction of their role to that of aesthetic and technical advisors responsible for a building’s form, appearance and representative qualities, they abandon what we see as a large area of their profession’s responsibilities, leaving behind a void that cannot be easily filled. Good hospital design can only flourish when its organization and processes, as well as its spatial logistics, infrastructure and programming are addressed in an integral manner.3 Ideally, this should culminate in a perfect fit between program and design. Hospitals are key elements in the healthcare system, which we view as a public service; they are obviously meant to enhance public health, which, ultimately, is measured by statistical data: life expectancy and the various other parameters used to define the quality of life. Often, the latter aspects are related to social and economic factors and lifestyle indicators. While medicine clearly has an impact on public health, its effects should be seen in a wider perspective. It is clear that city planning (by providing decent sewage and water supply systems and stimulating walking and physical exercise, for instance) and architecture (notably in the field of public housing) have been very important factors in improving life expectancy and quality of life.4 Investment of public money in medicine and medical facilities, it has been argued, should be proportional to their contribution to improved public health. In principle, the financial interests of hospitals do not always coincide with the objectives of public health. If a thorough upgrade of post-war housing projects yields better results in that regard than building new hospitals, then this is where the money should go. In many countries, only a small percentage of healthcare expenditure is allocated to prevention, while the cost of medical treatment continues to rise to unsustainable levels. Faced with the prospects of financial disaster, many public health systems need to improve their cost-effectiveness. If prevention of disease develops into the new frontier of public health, hospitals will be forced to reconsider their role and try to define their place in a continuum of prevention, health promotion and medical intervention (care and cure). Franz Labryga uses the term ‘health houses’ to describe facilities that ‘(…) will primarily be places that provide information, support, surveillance and prevention. Diagnosis 9

New North Zealand Hospital, Hillerød near Copenhagen, Denmark, Herzog & de Meuron, 2014. A serpentine band of two stories surrounds a large central garden on top of two layers. The roof on which the central garden sits is pierced by numerous lightwells that provide the outpatient department and the hot floor with ample daylight.

and treatment are no longer their main activities; instead, they focus on eradicating and preventing diseases’.5 One area that appears to be leading the way here is preparation for parenthood, including classes in relaxation; in some countries, notably England, these are already offered in community health centers.6 To reach this goal, the barriers between professional medicine and services providing disease prevention and health promotion will have to disappear and hospitals will need to accommodate the latter.7 Instead of remaining isolated organizations that only cover a part of the health continuum, they need to become aware of their social responsibility and play their part in renegotiating the sharing of responsibilities within this continuum. Architecture can facilitate this change of direction by promoting the “re-urbanization” of the hospital. Whereas public health is all about statistics, the hospital’s primary concern, we contend, should be to consider the patients’ perspective — the personal experiences of the people it has been designed to help. Health problems remind us of our mortality and of the fragility of our well-being. Confronting a disease is always a highly personal and stressful matter, and a hospital’s involvement in our personal affairs can make us uncomfortable. Therefore, hospitals should be designed to reduce stress and put patients at ease, and managed in a way that provides care with a human touch. The structure of this publication follows from these recent developments: the first part, ‘Defining the Hospitals of Tomorrow’, introduces a fundamental paradigm change: the transition to a way of thinking that puts the ‘end user’, in this case the patient, at the center of attention. This shift exceeds the ambitions of the older models of ‘patient-centered care’. Now, by making use of the latest innovations in information technology, the Internet and related devices, patients are able to become actively involved in monitoring and even controlling their own therapies. Moreover, they should be able to make choices for themselves: what are the best options for treating a condition? Which hospital has had the most success with the chosen treatment? What are the consequences of a specific procedure for one’s quality of life? Ideally, the range of alternatives would be clear and the past performance of all medical institutions transparent. Having outlined this new perspective, we continue with texts that focus on the implications of the public nature of healthcare, thus placing medicine within the broader spectrum of policies aimed at promoting public health. Obviously, making these changes affordable over the long term involves the financial aspects of running a hospital, which is the next issue we address. Finally, we conclude with ‘Changing Healthcare Needs’ on how demographic trends and the effects of globalization are likely to change the needs hospitals will have to meet. The second part, ‘Designing Hospitals’, introduces three phenomena that are increasingly influencing hospital architecture: new views on the optimal distribution of healthcare facilities (for instance, a concentration in large building complexes or a network of smaller facilities), the concept of care pathways and evidence-based design. A care pathway encom10

passes the series of interactions between a patient with a specific medical condition and healthcare providers, from the initial appointment for diagnosis to the moment medical care is no longer needed. Only portions of this trajectory are located in a hospital setting (the first appointment is usually with a general practitioner). Care pathways may include visits to therapists who work at home or in small clinics, nursing staff who may assist patients at home and in rehabilitation clinics. The organization of medical treatment around care pathways that ideally are monitored by the patients themselves — relying, among other things, on the Internet and related devices — will change the way hospital services are distributed. The example of the delivery suite is used to illustrate the spatial consequences of the choice of organizational principles adopted, highlighting a way of thinking that is relevant to all aspects of hospital architecture. The growing body of research in the field of evidence-based design, which uses scientific expertise to inform design solutions, has begun to have an influence on the way hospitals are planned. The second part of the book concludes with a historical overview showing that the profound changes we witness today have been preceded by similar transitions in the past. In the third and fourth part we enter the hospital itself, presenting it as a composition of the functionally defined units that make up a general hospital (excluding, however, the psychiatric wards). While discussing these components, we touch on a number of recurring themes concerning the contribution of each department to the patient care pathway. What is the objective of the procedures carried out in this department? Which areas of expertise and what type of information does it draw on? What is the expected interaction with the patient? What is the usual condition of the patient being treated in this department? How seriously does the disease — or the intervention — affect, for instance, his or her mobility, degree of consciousness and emotional state? What equipment is involved? If the treatment carried out in this department is part of a care pathway, what precedes it and what follows it? Then, we survey different design options. The third part, ‘Public Spaces’, focuses on the areas of the institution that are open to all users, including visitors and people living in the neighborhood. Public spaces include the entrance, halls, patios and the main traffic infrastructure, both indoors and outdoors. The fourth part takes us to the treatment areas. Portions of the latter are open to the public; in other parts, where the interaction between medical professionals and patients takes place, visitors are not allowed. Finally, a carefully curated selection of case studies documents general hospitals, children’s hospitals, university hospitals, specialized hospitals, community hospitals and rehabilitation clinics. Our approach conceives the hospital as a pattern of organized relationships, both internally and in the way it interacts with its environment, i.e. a ‘systems perspective’.8 We regard hospital architecture as a field requiring an open mind and a readiness to wander outside the traditional ways of thinking about architectural design and its boundaries. Hospital architecture is no longer a discipline monopolized by a handful of firms that constantly stress their unique professional skills in an effort to protect their territory against invasion from outsiders. It remains, however, a domain that requires intense involvement. ‘Architects will be called in on planning processes earlier, they will be asked to contribute a very broad range of expertise and they will be active during the entire lifespan of the building. In this sense, architects will serve as caregivers, practitioners of medicine and members of the patient care team’.9 Philip Meuser even urges hospital architects to think of themselves as science fiction authors.10 They must envisage future possibilities that promise to increase the performance of public health systems and their networks of buildings. This manual aspires to help them find their way in this rapidly evolving and important field.

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René Descartes (1596–1650). Portrait by Jan Baptist Weenix. Descartes is associated with the conviction that mind and body represent separate worlds, implying that people’s state of mind cannot impact on their medical condition in any way.

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Paradigm Change? The Perspective of the Patient Taking care of patients has always been the core business of hospitals, but as the ‘Short History of Hospital Architecture’ in this book demonstrates, this does not mean that they were built with the intention to cure people. That only became their primary mission with the advent of the scientific revolution of the 17th and 18th centuries, when the medical profession began to look more toward empirical science for inspiration. This change marks the beginning of an unending struggle against irrational views about illness and healing. There has never been a shortage of rituals, rites and the use of herbs and drugs, the alleged healing qualities of which often depended entirely on religious beliefs, superstition or salesmanship. The medical profession has made the fight against these dubious therapies one of its primary objectives and hospitals as we know them today are the physical manifestation of this fight. Since the late 18th century, they could be called ‘healing machines’ (machine à guérir), that is to say, buildings designed to cure those suffering from medical disorders. A machine is a technological device designed according to rational principles and because hospitals have defined themselves as machines run by medical professionals and technicians, they have always been seen as offering the best possible chance of recovery. The negative aspect of this outlook is that people were treated as objects of the same order as any other objects studied by the natural sciences. For centuries, medical professionals adhered to the Cartesian distinction between mind and body, seeing the latter as an object which functioned solely according to physical laws (and which was thus divorced from the workings of the mind). Diseases, therefore, had to be dealt with in much the same way as defective machines: by interventions based on the findings of the natural sciences. Medicine considered itself as one of them and thus treated mental illness, too, in the same way, i.e. as a mechanical failure. As long as the Cartesian separation between mind and body prevailed, the idea of taking into account the patients’ personal experiences was believed to be on a par with the superstitious concepts medicine had tried so hard to overcome. Ultimately, the emergence of psychology at the end of the 19th century began to undermine the Cartesian dichotomy, and since then it has become widely accepted that people’s mental states can have an impact on their physical well-being. Psychology, however, did not at first reject the view that mental disorders should be seen as mechanical failures. Moreover, the idea that patients should have a say in what is done to their bodies and minds — something which is now believed to reduce the stress on them — had not yet developed. In the 1930s, people’s personal experiences were increasingly seen as linked to their social and physical environment. Consequently, health-oriented interventions in the environment, previously focused on hygiene, now incorporated attempts to offer relief from stress. In the 1950s and 1960s, the modern housing estates that were then being built in large numbers came under fire, with experts blaming the living environment they provided for a great increase in psychological diseases associated with stress. Similarly, hospitals themselves began to be seen as stressful environments that hampered their patients’ healing processes. Friendlier, less machine-like architecture was promoted as a way to diminish stress, and patient-centered care became a popular slogan. Moreover, new organizational concepts were developed to alleviate the inevitable tension people experience when they are hospitalized. In the same vein, the evidence-based design movement that emerged in the United States in the 1980s began to explore the ways people react to their physical and social environment with the aim of learning how spatial design can influence medical outcomes. In sum, psychology was perceived as a way of exploring the link between personal experiences and objectively verifiable medical data. For quite some time, a paradigm shift has been underway that takes this evolution one step further, inviting patients to take an active role in treatment, something that in the United States is already considered a matter of ‘conventional wisdom’.11 ‘The elevation of the patient to partner’, the American Joint Commission concluded, ‘is not a ceremonial title bestowed for a “feel good” moment, but has significant implications for the quality and safety of patient care’.12 From the traditional, medical point of view, this turns the world

The Bijlmermeer, Amsterdam, the Netherlands, 1968–1975. The ‘Cartesian Dichotomy’ was increasingly challenged in the 20th century. In the 1950s, the phenomenon of stress was discussed at numerous medical conferences and linked to mental and physical health problems. New housing estates like the Bijlmermeer were seen as particularly unhealthy.

upside down, offering people who obviously lack professional knowledge and expertise — and are likely to be burdened with numerous unsubstantiated notions — the opportunity to interfere with medical procedures they know nothing about. Giving patients a say in the way they are treated clearly touches upon the very essence of medical practice and remains quite difficult to achieve. ‘In ideal circumstances, hospitals would be highly responsive to the needs of their patients. In reality, this is rarely so. Patients are in a weak position. They are in an unfamiliar setting, vulnerable because of their illness and their lack of information and dependent on others’, Martin McKee and Judith Healy conclude in a report of the Joint Commission, a not-for-profit organization that assesses health programs and organizations in the United States.13 ‘Although it is self-evident that care should be focused on the needs of the patient, in reality many hospitals are run more for the convenience of the staff.’14 Obviously, it is very difficult to reconcile the hospital as an impersonal ‘healing machine’ with the hospital as a caring institution that not only offers treatment, comfort and support, but also invites patients to take responsibility. This paradigm shift coincides with a new definition on health, one that is widely promoted by the World Health Organization: people can consider themselves healthy if they can do anything they want without being hampered by their physical or mental conditions. Clearly, this approach puts personal experiences at the center and breaks away from the 13

The Unfallkrankenhaus, Berlin, Germany, Karl Schmücker und Partner, 1997, is the result of the reconstruction and extension of a historical pavilion hospital. It fits into its surroundings rather than dwarfing it, adding a friendly dimension often lacking in older facilities.

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DEFINING THE HOSPITAL OF TOMORROW

view that people are ill, and therefore in need of medical treatment, if from an objective, scientific point of view one or more ‘mechanical’ failures and dysfunctional parts can be identified (which is almost always the case). Political and economic trends, not public pressure, are decisive for this paradigm shift. In an effort to control public health expenditures, many countries in Western Europe are moving away from healthcare systems in which the volume and the costs of medical treatment are determined by state bureaucracies. The trend toward transferring responsibility to the ‘end user’ is affecting all aspects of the economy, and there is little doubt that it will also transform medicine. Ideally, the individual customers should have a say in the cost and the quality of the services they are being offered; patients should use their purchasing power to force providers to adjust their services to the needs of the patients. The paradigm change obliges patients to better understand the options open to them; they have to be free to select the hospital or medical specialist of their preference, and they need to understand that they share responsibility for all decisions concerning their health and treatment. In order for patients to make rational choices, data such as the effectiveness, quality and costs of different therapies, the track record of medical specialists and the performance of hospitals have to be transparent and freely available. However, most countries still have a long way to go before this is the case. Technology, especially the Internet, plays a fundamental role in this paradigm shift. If the unprecedented abundance of information now readily available can be properly managed, information technology may help to create the ‘expert’ patient. ‘By increasing the likelihood of preventions over cure’, Sunand Prasad, a British hospital expert, believes, ‘such a patient will reduce expenditure in the health system’. In his words: ‘The costs of creating the expert patient must be far less than the costs of treatment of preventable diseases.’15 The way the Internet facilitates communication between the medical establishment and the patients helps to further reduce the gap between the two groups. Instead of obliging patients to visit the doctor, certain procedures — from diagnosis to monitoring and follow-up — can be organized through websites or apps. Why, then, is it taking so long for this paradigm change to take hold more broadly than it has to date? Obviously, resistance from the medical world continues to a certain degree. Many patients are reluctant to take on any responsibility for their treatment and prefer to surrender all initiative to the medical authorities. The substantial costs involved in public health also tend to foster conservatism: ‘The great expense of hospitals, together with their complexity and user requirements, militates against change. Should something that is untried be planned and built?’, Lawrence Nield wonders.16 Despite all this, the momentum for change appears to be irreversible. If the necessary conditions are met — if the patient is well-informed, if the effectiveness of treatments and performance of providers is transparent and, ideally, if a network of medical and non-medical facilities is in place — the shift of responsibility to the patient is bound to enhance rather than diminish the quality of healthcare. This empowerment will transform the medical machine into a service provider that takes its clients seriously.

COR WAGENAAR, NOOR MENS

Healthcare as a Public Service

Domenico di Bartolo, Cura e governo degli infermi (Cure of the sick), fresco in the Santa Maria della Scala, Sala del Pellegrinaio, Siena, Italy, (from the Episodes from the Life of Blessed Sorore), 1440–1441.

In the Middle Ages, hospitals were established as social institutions and remained so for centuries. They were public facilities inasmuch as they addressed a public issue: care of the poor who fell ill, providing food, shelter and succor, though hardly any treatment in the modern sense. Unless charity institutions intervened, the poor would live out their lives in misery, especially if illness prevented them from earning a living. In striking contrast with the poverty of their inhabitants, hospital buildings soon developed into wealthy, representative landmarks. Often, their sponsors endowed them with paintings, sculptures and lavishly decorated rooms for the people who managed them. Some hospitals even became patrons of the arts.17 Still, even the best endowed hospitals remained almshouses, offering no therapies that could not be found elsewhere. It was only in the late 19th century that they developed into institutions providing the best medical care available, mainly because of the introduction of Röntgen’s X-ray machine in 1897 that required patients to come to them for treatment. Whereas until then the well-to-do avoided hospitalization at all costs, they now had no alternatives. The cost of hospital treatment began to rise, and though charity often remained a valuable source of income for hospitals, patients frequently had to pay for their care. Since the poor could not afford these costs, hospitals temporarily lost their public function, a situation which prevailed in most countries until the introduction of public health systems. It can be argued that ‘hospitals fit many of the criteria of a public good. There are benefits for society from a socially cohesive, healthier and more productive population.’18 Public healthcare systems are usually either run by the state (the Bevan model) or organized within a state-controlled framework based on health insurance policies (the Bismarck model). Why did public authorities enter this field? With the exception of semi15

The vanitas paintings, here Finis Gloriae Mundi and In Ictu Oculi, were painted by Juan de Valdés Leal for the Hospital de la Caridad in Seville, Spain, in 1670–1672.

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DEFINING THE HOSPITAL OF TOMORROW

military institutions intended to take care of wounded or disabled soldiers — the so-called ‘invalids’ — the state showed little interest in public health before the 17th century. Cities built charitable hospitals, but they were also intended to concentrate the urban poor, preventing them from endangering public safety. What gave public authorities the idea that they needed to enter the field of public health? Historically, there have been three major reasons. First, according to the mercantilist policies dominant in the 17th and 18th centuries, in the perennial rivalry between nations, the health of the citizens had a major impact on their economic performance. The healthier the people were, the higher their productivity would be. Second, in the latter part of the 18th century, the philosophers of the Enlightenment maintained that the provision of healthy living and working conditions should be seen as a basic human right. They held that the flaws in man’s political, economic and physical environment were the main cause of all social evils — including the uneven distribution of good health — refusing to look upon these evils as consequences of a divine order that people had to accept. These ideas, which provided a major impetus for the scientific and technological revolution that was thoroughly transforming society, had a large impact on hospital architecture. Public authorities were called upon to create institutions designed to assist nature in realizing the healing potential generally attributed to it at that time. This was the period when the view gained ground that the construction and layout of hospitals should be determined by a rational analysis of its function. Hospitals were now defined as places that should contribute to healing people and should offer patients a healthy environment. Clean air and a natural setting were seen as far more effective than medical treatment per se. Third, a series of deadly epidemics in the 19th century drove home the point that contagious diseases tended to affect the entire urban population. They were becoming a public menace, forcing the public authorities to take action. Cholera epidemics resulted in a death toll of 14,000 in London in 1848 and 6,000 in 1866. Hamburg was hit by epidemics in 1822, 1831, 1832, 1848, 1859, 1866, 1873 and 1892. Hardly any city in Europe or the Unites States escaped the dire consequences of these plagues. Continuing the work French cartographers had begun in the 18th century, medical professionals produced maps showing which parts of cities were most affected and tracing how the disease spread. Globalization was already having an impact here; for mapping the incidence of epidemics on a global scale revealed that steam-powered ocean liners were accelerating their spread between continents. Although many hospitals were founded in the years when mercantilism dominated political thinking, the introduction of sewage systems, the supply of clean water and public housing may well have been the most effective contributions to public health and also the most expensive. These measures shaped and reshaped cities all over the world, leading one of the founders of public health, Rudolf Virchow, to maintain that medicine should be seen as a social science and politics as nothing else but medicine at a large scale.19 Private hospitals founded with the aim of making a profit appeared only in the late 19th century. In a fully private system, patients pay for all healthcare services themselves. Advocates of private systems argue that since health is essentially a private affair the state should not become involved in it. At the other end of the scale are fully public systems in which the state uses tax money to pay for all healthcare costs while also providing this healthcare. In practice, most countries have adopted mixed systems consisting of both private and public elements. Some require residents to obtain health insurance policies, granting subsidies for those who cannot afford them, as is the case in many Western European countries. Public systems invariably incorporate cost control mechanisms, and they generally adopt a supply-based perspective in attempting to achieve their goals. In this model, access to public health policies can be limited to those in the lower income brackets and exclude those who can afford to pay for medical services. Sometimes, the public authorities introduce annual budget ceilings per therapy or per healthcare provider, as well as for the system as a whole.

An 1897 set-up for taking an X-ray of the hand and diagnostics in the 1920s. X-ray machines marked the beginning of a development that would transform hospitals into hubs of medical technology.

Since the 1990s, another cost control strategy has become popular in many European states, namely the introduction of demand-driven mechanisms similar to those at work in any free market economy. Ideally, this encourages patients to act as consumers: they are expected to evaluate the effectiveness, quality and the prices of therapies offered by a potentially wide range of providers, the assumption being that this inevitably results in lower prices and, therefore, a less expensive public healthcare system. The transition to demand-driven mechanisms, however, requires complete transparency in outcomes and costs. Already in 2006 the US authorities issued an ‘Executive Order’ urging more transparency in the hope that it would spur competition. ‘Transparency of pricing will likely foster what is now absent in healthcare — a price-sensitive consumer.’20 Patients’ perception of quality, shaped by medical outcomes and their experience during hospitalization (personal contact, empowerment, trust, safety, privacy, quality of food, behavior of nursing staff, etc.) is expected to be decisive. However, if insurance companies represent their patients and buy healthcare in bulk from providers on their behalf, as is usually done, costs are likely to be the predominant factor in the provider selection and contracting process. Recently, lump-sum compensations per therapy (case combination model or diagnosistreatment combinations) were introduced with the goal of achieving a uniform hospital financing system that covers medical service compensation as well as building maintenance and refurbishment within a single-case fee. A comprehensive system needs to allow for long-term building investments in the interest of improving the quality of medical care. Such strategic investments have not been possible in a system where budgets are split between building costs and the operational costs of health services. The case compensation model has also displayed shortcomings; for its focus on revenue optimization leads to a failure to set long-term goals for improving an institution’s medical services. Whether or not the market-oriented public systems have been more effective in curbing healthcare costs and improving quality than the traditional supply-driven public systems is difficult to determine. In terms of total costs, it is hard to define what an optimum mix of private and public roles in the system would be. Apart from the costs, however, other aspects are equally relevant. Whereas the demand-driven systems are expected to serve the individual needs of the patients better, critics fear that without a coordinated and well-balanced network of healthcare facilities they may result in fragmentation. On the other hand, the supply-based systems, which allow for a higher degree of planning, are often seen as inflexible and coercive, virtually barring the patients from having a say in the way they are ‘processed’ by the system. In practice, the preferences for either system are hardly ever based on a clear assessment of the way they perform in terms of financial efficiency, patient satisfaction and the quality and effectiveness of services. One lasting achievement of the experiments with market-oriented systems, however, has been a much stronger HEALTHCARE AS A PUBLIC SERVICE

17

emphasis on patients’ rights and choices than was customary only a few decades ago. This trend is now visible in supply-based systems, too, suggesting that the (assumed) advantages of market-oriented systems in terms of patient empowerment can also be integrated in those systems.21 Does the existence of public healthcare systems mean that their hospitals are public buildings in much the same way their medieval predecessors were, i.e. institutions that represent society’s shared values? Seemingly not, since public health is now a field marked by continuous political debate. Nevertheless, hospitals are still among the city’s most important public buildings.

Topographies of epidemics started to appear regularly in the 1830s and 1840s, with cholera forming a major focus of these early maps. They played an important role in identifying the source of the disease. This map by Dr. J. N. C. Rothenburg visualizes the cholera sourge of 1832 in Hamburg, Germany.

Following three outbreaks of cholera in London, UK, the civil engineer Sir Joseph Bazalgette (standing top right) developed a system of sewers for the city that was built 1859–1875, the largest and most expensive hygienic campaign of the 19th century. This ensured that sewage was no longer dumped onto the shores of the River Thames and thoroughly improved public health.

18

DEFINING THE HOSPITAL OF TOMORROW

GURU MANJA, COLETTE NIEMEIJER

The Business Case for Hospitals In 2007, the annual per capita healthcare expenditure in the US was $ 7,500, for a grand total of $ 2.2 trillion. More than a third of that sum was spent on hospitals; in most European countries they even account for half of the costs.22 Between 2012 and 2014, healthcare costs represented 17.1Æ% of the gross domestic product in the United States and 11.3Æ% in Germany. In the United States, hospitals are the second largest provider of jobs in the private sector; in Europe, 10Æ% of the total workforce is employed in healthcare — between 2.9 and 5.5Æ% in hospitals.23 About two thirds of healthcare budgets is typically spent on personnel. However, the authors of a study initiated by the European Observatory on Health Systems concluded that hospitals ‘have received remarkably little attention from policy-makers and researchers’.24 They also maintain that ‘the nature of the healthcare marketplace and its influences may act against the rational application of healthcare interventions. A number of perverse incentives act on the healthcare marketplace, including industry and its relationship with those who license, reimburse and prescribe its products.’25 The authors conclude that ‘(…) Just as “war is too important to be left to the generals”, hospital care is too important to be left to hospital managers and health professionals’.26 Precisely because healthcare is a public service, the business case of individual hospitals follows the same principles of sound management that are customary in other sectors. The architecture of hospitals affects their performance as economic units or, to put it more provocatively: their spatial qualities and their business model coincide. From a public health perspective, mistakes at the design stage result in a recurring waste of financial resources, for instance by creating overcapacity and by letting very expensive equipment stand idle. Given the substantial cost of healthcare buildings and the constantly growing demand for their services, hospitals need to function as efficient production facilities while not neglecting the need to provide compassionate care. Finding the right balance between these objectives is the main issue in healthcare today. Architecture can play a crucial role in this regard, but it can do so only on the basis of sound business models.27 In other words, architects working on the planning of hospitals need to have a basic understanding of such models, if they wish to convince hospital managers and financial administrators of the feasibility of their designs. They have to be ‘fluent in the language of business if they want to be heard.’28 The investment required in building or renovating a hospital is usually so large that the organization must base that investment, along with its programming and design decisions, on a sound analysis of long-term consequences. Factors such as the strategic positioning of the hospital relative to other hospitals, the distribution of healthcare facilities in the region and developments in medicine and technology are the most important factors in assessing the soundness of its business model. This requires the management, financial backers and the other parties involved to come up with a sound strategy for anticipating future changes in healthcare financing, care delivery processes and technology — all of them rapidly evolving fields. While the annual costs for buildings (depreciation and financing) and the technical infrastructure of hospitals are modest when compared to the total operating expenses, the physical infrastructure has a major influence on the quality and operational effectiveness of the hospital. A well-designed and well-built hospital can contribute substantially to improving quality and medical outcomes, reduce costs and, ideally, increase revenues. In other words, just as the contribution of architecture to better healthcare delivery depends on a sound business model, so, too, a sound business model is facilitated by good architecture. If one regards the hospital as a relatively autonomous organization, a sound business model means running it in an economically sustainable manner. Just like any other business, the hospital generates revenue by selling products. The products can be complete packages from initial diagnosis to treatment and follow-up (diagnosis-related groups or DRGs, for instance) or individual components such as a diagnostic test, an outpatient 19

appointment, a specific therapy or a night’s stay. Prices can either be negotiated and agreed on beforehand (for instance in contracts between providers and insurance companies) or based on the incurred costs (time and materials). Other sources of revenues could include teaching, subsidies, royalties and diagnostic services for third parties. Since medical processes are labor-intensive, personnel costs represent the largest share of the hospital’s budget. The medical staff can be on the payroll of the hospital, but the hospital also often acts as a service provider that facilitates the medical specialists’ private businesses. Medicines, medical instruments, prosthetics, disposables, food and nutrition, energy and maintenance make up most of the rest of the operating expenses. From the 1940s to the late 1990s, a process of continuous economic and demographic growth accompanied the evolution of healthcare systems. Longer life expectancies, advances in medicine and technology, and sustained increases in prosperity resulted in ever more and larger healthcare facilities. Now, new economic and demographic realities in Europe and the United States, the costs of public healthcare systems and the rediscovery of preventive health strategies have rendered this trend obsolete. The business case for building new hospitals or for major renovations can be made only if these investments significantly contribute to the realization of a sound business model. There is, for example, no business case for waiting areas in a consumer-driven healthcare delivery model. There is, however, surely a business case for creating streamlined patient processes. Whenever it is possible and sufficient for consumers to consult a specialist online, then there is no case to be made for this group coming to visit outpatient departments (nor, therefore, to build capacity to accommodate such visits). Our criterion for a valid business case for a new hospital building is this: that every component of it must be essential to and actively contribute to safe and efficient patient processes and information flows, with fewer errors, better quality of care and better outcomes, at a significantly lower price and with less resource consumption and overall effort than occurs at comparable existing facilities. It must also remain fit for purpose for at least 30 years, with relatively minor modifications and upgrades during that period — something which will require carefully considered flexibility/cost trade-offs. The business case can be deemed valid only if it has been tested against and been found to be satisfactory in a variety of long-term scenarios. These scenarios need to take into account the potential effects of a range of factors: variability in demand, the emergence of breakthrough technologies, drugs and devices, the appearance of new diseases, improvements in care delivery processes and so forth. The most crucial task one faces while developing the business case is estimating required future capacity (beds, operating theaters, etc.) — the starting point for programming — and, based on that, determining the investment (and debt) that the hospital can absorb at acceptable risk. The needed capacity is dependent on the product portfolio and the patient categories (and numbers) that the hospital expects to serve. The most frequent mistakes organizations make in this process are 1) wanting to do everything, i.e., not making clear choices in terms of the product portfolio and patient categories; and 2) playing it too safe, i.e., factoring in every potential chance of capacity shortage at peak demand. The usual outcome is programming much more capacity than the hospital will ever use. The required capacity can be estimated on the basis of a fine-grained analysis of the current capacity utilization at the departmental level (inpatient departments, operating rooms, outpatient departments, etc.), employing data that is usually readily available. The capacity-usage analysis illuminates a number of important issues: actual vs. perceived capacity requirements (now and in the future), ways of improving short-term process and capacity utilization, and the optimal location of departments relative to each other. Hospitals should make sure to cluster departments from the perspective of what is safest, most efficient and most convenient for patients rather than from the perspective of physical proximity and the convenience of staff. Further capacity optimization is possible through an analysis of patient care pathways.29 Sound business cases should favor the use of end-to-end patient care pathways, 20

DEFINING THE HOSPITAL OF TOMORROW

and not focus solely on investments in specific facilities or departments, such as operating rooms or inpatient beds. Programming should revolve around the identification of ‘capabilities’ catering to these end-to-end patient care pathways, which may be thought of as self-sustaining organizational entities (business units, for instance) executing a distinct set of processes to treat a specific group of patients for a specific diagnosis. Moreover, the organization may anticipate the possibility of combining various business models. Thus, a project for a new hospital might distinguish three zones: the actual hospital (with hot floor and wards); a zone built by the hospital but run by private parties (containing functions that can be outsourced: shops, restaurants — part of the activities in the public spaces); and a zone designed by the hospital but built and run by private investors, which would likely attract such facilities as a hotel, housing for senior citizens and wellness and sports centers. Once the program, the investment and the implementation plan are finalized, a financial model can be developed, including risk and sensitivity analysis. The key here is to focus not on the model’s output, which is essentially a set of financial ratios, but on how robust the input is. This requires the business case to be built from the bottom up, based on investment in the capacity required for a set of patient care pathways catering to an (almost) guaranteed patient demand — the core of the hospital. The investment level that the hospital can absorb at acceptable risk must be based on the turnover of this core element, in combination with the hospital’s current financial health. The scarcer the resources, the more urgent the need for qualitatively better and, therefore, more efficient care pathways. By integrating the optimization of care pathways and of capacity utilization into the building design process, architecture can contribute substantially to and, ideally, embody a sound business case.

THE BUSINESS CASE FOR HOSPITALS

21

COR WAGENAAR, NOOR MENS

Changing Healthcare Needs The planning of new facilities as well as the large-scale reconstruction of existing ones requires a clear view of future needs. To a remarkable extent, these needs can be predicted: ‘Prognoses can be based on the basis of the length of time between causation and the appearance of disease.’30 Given adequate information about the composition of the population, including both basic demographic facts and data on lifestyles, jobs, education and wealth, as well as on consistent trends among these factors, one can safely assume, for instance, that regions experiencing economic growth will adopt lifestyles that typically promote obesity; and where this occurs, the period of time it takes before the diseases associated with obesity manifest themselves can easily be forecasted. Hospitals typically draw people with diseases that cannot be treated without the high level of professional skills and the advanced medical technology only they can offer. The great majority of their patients suffer from disorders that are not contagious. Although the far more common, so-called non-communicable diseases (NCDs) usually lack the spectacular and frightening aspects of, for instance, Ebola, they account for 75Æ% of deaths worldwide and as much as 86Æ% in Europe. Whereas not a lot can be done to prevent epidemics, it is estimated that 80Æ% of cardiovascular diseases and 40Æ% of all cancers could be avoided. Likewise, changes in the relative incidence of illnesses must be taken into account. Some afflictions that were widespread in the past have virtually disappeared, while others have taken their place. For those charged with preparing hospitals to cope with future needs, statistical data on demographic trends and the occurrence of diseases is indispensable. In 1796, Edward Jenner ushered in a whole new branch of medicine when he introduced a vaccine against smallpox, and thanks to vaccination campaigns some diseases have virtually disappeared. However, the emergence of SARS (severe acute respiratory syndrome) in 2002, the chicken flu caused by the N5N1 virus that unleashed a pandemic in 2009, and subsequently the swine flu and Ebola all serve to demonstrate that new contagious diseases and epidemics can occur at any time. In the treatment of non-communicable diseases medical progress has been impressive owing in large measure to the pharmaceutical industry’s continuous development of new drugs. Equally crucial has been the introduction of new imaging technologies — magnetic resonance imaging, positron emission tomography — which has revolutionized diagnostic procedures. And thanks to highly sophisticated surgical procedures (sometimes using robotics), minimally invasive operations have become an everyday reality that was unthinkable only a decade ago. Undoubtedly the most impressive advance in the last decade has been the development of gene technology. The promotion of healthy lifestyles is another development in public health. Social stratification also has a bearing on health issues. In some European countries, the difference in life expectancy between the upper classes and lower classes is eight years.31 If unhealthy lifestyles prevail, this will lead to an increase in the demand for healthcare services. However, unhealthy lifestyles do not shorten the time during which people need medical assistance. Architects and urbanists can play a vital role in providing environments conducive to health. ‘Healthy cities’ should provide clean air and limit automobile use while favoring pedestrian and bicycle mobility. Aging populations are an important factor in public health. The need for medical treatment correlates closely with age and reaches a peak in the last years of our lives: the larger the number of elderly people, the higher the demand for medical assistance. However, the age when medical problems first manifest themselves remains about the same, at around 40. The growing number of the elderly combined with the prolongation of the period when they require medical attention is expected to result in a steep rise in the need for healthcare. ‘Healthy aging’ has become a well-known concept all over the world. Strategies to support healthy lifestyles will also contribute to better integrate the hospital in society.32

22

DEFINING THE HOSPITAL OF TOMORROW

GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Distribution of Healthcare Facilities: Centralization, Decentralization and the Network Hospital Redefining the Hospital The word ‘hospital’ refers to a wide range of very different facilities providing technologically advanced medical diagnostics and treatment. Apart from the classical type — a building or a campus with various buildings that comprise a single hospital organization — there are ‘focused factories’ that specialize in specific diseases or conditions. These vary in size from single-doctor operations to large complexes dedicated to the diagnosis and treatment of certain diseases. Sometimes, outpatient departments function as satellite clinics of large general hospitals; in other cases, primary care providers and general practitioners constitute an integral part of the hospitals’ services. Every healthcare system has its own particular way to distribute medical services. However, due to the urgent need to improve quality and reduce costs, healthcare policymakers and those responsible for its financing are increasingly attempting to (re)distribute facilities more efficiently. From their perspective the primary question is: where is the best place to provide the best care at the right time at the lowest cost? In order to answer this question, we need to rethink healthcare in terms of a ‘stepped care infrastructure’ involving close cooperation between providers at different stages of the various therapies dispensed, including ambulatory care, rehabilitation, care for the chronically ill, psychiatry and hospices. In the last decade, many hospitals have begun to function as parts of network organizations in which specialized institutions collaborate intensively to achieve both high quality and economies of scale. Debates about centralization versus decentralization, and the definition of the various types of facilities needed in the latter case, revolve around a number of recurring themes, with factors such as the type of disease in question, scale and travel times leading to different solutions. Which model provides better patient-centered, affordable care? What are the consequences of that choice for, say, the level of control that patients with chronic diseases have over their therapies? Are relatively simple and low-risk diagnosis and treatment best accommodated by primary care centers? Should complex care be concentrated at the regional level? Is integration of the standard services with elderly care and psychiatry advisable? Remarkably, the study of which strategies to employ when considering the redistribution of healthcare facilities appears to have been largely neglected. Indeed, until recently improving the quality of care usually meant building larger and more consolidated healthcare facilities. Clustering scarce and expensive resources at one location made sense and scale held out the promise of efficient delivery, while delivering healthcare and sharing information across distributed facilities was cumbersome and could pose a safety risk for patients. New Opportunities for Decentralization At present, however, the constraints that made centralization desirable are fast disappearing. The idea of breaking away from massive complexes and replacing them with networks of mostly smaller facilities has gained worldwide acceptance; it initially appeared both in Europe and the United States in the early years of the 21st century.33 Concentration of specialized care, on the one hand, and decentralization of medical consultation and less high-level medical intervention, on the other, is now considered a valid option — even in the Netherlands, a country with a traditional preference for large-scale facilities.34 As Pierre Wack noted, ‘Especially in times of rapid change, the inability to see an emerging novel reality can cause strategic failure.’35 What are these novel realities? Certain forms of chemotherapy and complex diagnostics can now be self-administered by patients at home. If the artificial kidneys currently in development are successful, entire dialysis centers could soon be rendered unnecessary. Portable imaging devices and high-speed data networks are redefining radiology departments — radiologists working from home studying images sent by mobile CT scanners from dispersed locations close to patients’ homes could become commonplace. Innovations such as mobile stroke units are extending the emergency department’s reach to the patient’s doorstep. Absolutely essential in this 23

regard is the acceptance and general application of the century-old principle of ‘a centralized medical record, stored in a single repository, and capable of traveling with the patient’, as developed by Dr. Henry Plummer and Mable Root at the Mayo Clinic in 1907.36 The Internet has the potential to make information stored in medical records available anywhere at any time, thus enabling hospitals to function as networks of distributed facilities and bringing healthcare closer to individual communities. Improved understanding of diseases and the greater efficacy of specific treatments, combined with smaller, cheaper and easierto-operate equipment will make it possible to create satellite diagnosis and treatment centers. Obviously, all this does not mean that large, centralized hospitals should be seen as relics of the past. Teaching hospitals need to attain a sufficient scale to function efficiently as research and educational institutions. Complex care and the treatment of rare diseases requiring highly trained specialists and advanced infrastructure is best centralized. Likewise, acute and urgent care is best provided in centralized emergency centers that remain fully operational around the clock. For all other healthcare facilities, the question that needs to be answered is: what is the justification for clustering specific health services in one particular building at one particular site? Demand, scale and location must be rigorously analyzed in the planning phase. Which trade-offs need to be made in determining which processes, and thus which facilities, to centralize, and which to distribute? One feature that all medical facilities share is that they are increasingly focused on intensive medical intervention, relegating all other therapies to organizations that can rely mainly on staff with less training. ‘The burden of proof’, John Posnett writes, ‘must be with those who propose concentration to quantify the expected benefits and costs and to explain the process by which benefits will be realized in practice’ as ‘(…) costs cannot generally be presumed to be lower or outcomes better in larger hospitals.’37 In Europe and the United States, there is a marked trend toward a distinction between relatively small community hospitals and hospitals that exercise a monopoly over complex, high-risk interventions. Judith Healy and Martin McKee dub the latter the ‘separatist’ hospitals; they provide ‘services that primary care practitioners and community-based specialists are unable (…) to undertake’.38 They can be either large facilities that offer the full range of therapies (and are often teaching hospitals) or specialized, so-called ‘focused factories’ that concentrate on specific sets of diseases. If healthcare systems become more transparent, these specialty hospitals may become more popular, contends the Joint Commission in a report issued in 2008.39 Geography and Context The first set of factors influencing planning and composition relates to the context in which healthcare providers operate: geography, demography, government policies, preexisting infrastructure and the available resources. Indonesia, with 0.204 doctors per 1,000 inhabitants and a total population of more than 234 million people spread over 6,000 islands, has a different set of geographical and resource constraints on the distribution of healthcare facilities than Austria, a mountainous, landlocked country with 4.86 doctors per 1,000 inhabitants and a population of 8 million. The affordability, and therefore the composition and distribution of healthcare facilities in Nigeria, with a per capita GDP of around US $ 1,500 per year, is obviously different from that in Norway, with a per capita GDP of around US $ 100,000. Aging populations with stagnant growth need different healthcare services and face different workforce constraints than relatively young and growing populations. Countries with comparable health indicators, such as the United States and Cuba, may have completely different healthcare policies and infrastructure. Life expectancy in Cuba is higher than in the United States, with less than a tenth of the latter’s healthcare costs per capita.

24

DESIGNING HOSPITALS

The Hospital The second set of parameters defining the possibilities and constraints of decentralization concerns the hospital itself. Which part of the care path can a patient independently and safely manage and monitor at home and which part can be delivered by primary care providers? Is it really necessary to build outpatient departments at the same location as the high-tech and intensive care facilities such as operating and catheterization rooms and inpatient departments? Low-risk patients needing treatment for a specific diagnosis might be able to follow their complete care path at decentralized facilities that lack fallback options such as an intensive care unit, while high risk patients with the same diagnosis might need to follow at least part of their care path at a specialized center. In any case, the role of the hospital in the regional healthcare landscape also influences its composition, chiefly how the new facilities will complement or conflict with the existing healthcare facilities. This way of thinking is not new. In 2004, the Netherlands Board of Hospital Facilities sponsored an ideas competition for the ‘Hospital of the Future’. The winning entry was by Venhoeven CS Architecten and Itten + Brechbühl. They approached the hospital as a collage of different functional elements.40 Functionally, the inpatient departments are more similar to a hotel than they are to the rest of the hospital, and the many offices involved can be very similar to those in a normal office building. In other words, from a functional perspective most of the elements that make up a hospital are not specific to hospitals but rather generic; what is specific to hospitals amounts to no more than a third of the building, which may be termed the ‘core hospital’. The generic elements need not be designed differently from their counterparts outside the healthcare sector, and often these spaces form part of a well-advanced typology. Office expert John Worthington noted that the criticism of today’s new hospital construction could have been directed against office buildings 30 years ago and that there the problems in question have since been addressed.41 More important, some of these office or hotel-like parts need not be located at the hospital. They could be peeled off, as it were, and transferred to other locations — hence the name for this concept in the Dutch healthcare sector, ‘schillenmodel’ (shell model).

Early example of the hospital as a collage of different functional elements. Winning entry by Venhoeven CS Architecten and Itten + Brechbühl for the 2004 Netherlands Board of Hospital Facilities’ ideas competition for the ‘Hospital of the Future’

DISTRIBUTION OF HEALTHCARE FACILITIES

25

Operational Logistics The third question concerns operational logistics and specific local constraints. Is the projected diagnosis and treatment volume sufficient to ensure efficient operations at each facility? Distribution scenarios requiring personnel to travel between locations, for instance, are dependent on specific constraints. Travel is more acceptable in densely populated urban areas than in sparsely populated rural ones. Rural centers will, therefore, need to focus more on scaling their operations efficiently than do urban ones, asking for example whether a nurse practitioner or an ENT surgeon can be productive at the location for a whole day. Digital Hospital The availability of a reliable and secure digital infrastructure with failsafe backup systems is indispensable for the modernization of healthcare. Apart from electronic patient records, the analysis, redesign and monitoring of care pathways based on the information available in these records can become powerful management tools for the medical staff as well as, ultimately, for patients. Digitized care pathways can become the backbone for e-health applications that are now being developed throughout the world. It is important that the hospital organization ensures transparency and easy access to information. After all, Dr. Henry Plummer successfully introduced ‘a centralized medical record’ already in 1907, ‘stored in a single repository and capable of traveling with the patient’; it was managed using a system of pneumatic tubes. Programming Hospital Buildings The next step is to determine the scope and capacity of the program and the composition of the hospital building. This involves adding up the function and capacity prognoses, eliminating redundancy and developing ‘what-if’ scenarios. The result of this exercise is a range of function and capacity prognoses with varying levels of probability for the specific hospital building in question. This information is sufficient to determine the minimum capacity required for the core hospital. For instance, the conclusion might be: ‘this facility will be able to utilize efficiently at least 300 inpatient beds and ten operating rooms in all scenarios for the next 10–15 years. The number of additional beds varies between 20 and 100 and that of the operating rooms between two and four.’ Depending on its willingness to risk overcapacity, its financial resources and the potential alternative uses for the additional 20–100 beds and two to four operating rooms, the hospital can make a wellinformed choice in the range of 300–400 beds and 10–14 operating rooms at that specific facility. From an architectural point of view, many generic components such as care facilities could become ‘invisible’ by decentralizing them. Generic buildings loosely distributed in the urban tissue could readily accommodate them.

26

DESIGNING HOSPITALS

GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

The Design of Hospitals: Care Pathways The redistribution of healthcare facilities and the ‘decomposition’ of standard hospital designs result in healthcare networks with many access points. From the perspective of the traditional hospital, this seems to increase fragmentation. From the perspective of patients, however, the physical concentration of services and medical specializations in the traditional hospital does not sufficiently compensate for the psychological fragmentation they often experience as they are passed from one specialty department to another. The vast majority of encounters between patients and medical professionals during hospital visits are brief — sometimes not much longer than five to ten minutes. Within this short timeframe, the patient’s medical history is retrieved and interpreted, the symptoms and the ailment diagnosed and discussed and the subsequent diagnostic and treatment options proposed, analyzed and chosen. From the perspective of the professional, each meeting is an isolated event and is largely focused on his or her highly specialized expertise. ‘At best, medical staff (…) spend precious time reading what other professionals have written in a patient’s medical record before making their own plans and decisions. At worst, the disjointed and retrospective nature of care planning creates opportunities for avoidable patient safety and clinical treatment/testing errors.’43 For patients, on the other hand, having to deal with illnesses is a continuous process that may dominate their lives for as long as it takes to cure them. They form the living link between all the steps in the process. Growing awareness of the benefits of patient involvement in the decision-making process and the need to improve safety and coordination between the various actors in the diagnostic and treatment processes served as catalysts in the development of ‘care pathways’ in the 1980s and 1990s. Care pathways are one of the most effective mechanisms for improving predictability, cooperation and coordination in medical processes, and they were immediately welcomed as a tool for improving the quality of healthcare. Care pathways ‘have had a tremendous appeal (...) to the point that hospital leaders concluded that the competitive environment did not allow the luxury of waiting for rigorous tests of (their) effectiveness’, the editors of the International Journal of Care Pathways concluded in 2012.44 The use of these pathways considerably improved the coordination of medical procedures, while at the same time facilitating communication with family and friends, integration with primary care and follow-up after patients were released from the hospital.45 Communication technology is of course a prerequisite for a successful implementation of care pathways. A care pathway represents a set of evidence-based, streamlined and standardized medical processes for the diagnosis and treatment of a specific disease; it also serves as a best-practice reference and reduces uncertainties and the scope for errors. Care pathways have the potential to improve compliance with protocols and regulations, help reduce costs, better monitor effectiveness, promote continuous improvement of diagnostics and therapies and optimize capacity. Care pathways can also be useful in the development and testing of new therapies. Most importantly, care pathways have the potential to be a very effective tool for guiding and testing the programming and design decisions in planning hospital facilities. The development and deployment of care pathways is a complex process. This has to do with the vast range of diseases involved, the difficulty in getting medical professionals to agree on what constitutes ‘best practice’ and the level of precision required to determine the causal relationship between interventions and outcomes, as well as the practical challenges of gathering valid and consistent data for monitoring and analysis. The standard method used for the development of care pathways is, therefore, a long evolutionary process involving significant investments of time and effort. New developments in diagnostics and treatment may necessitate adaptations in care pathway implementation. The potential benefits of pathways as a tool for programming and design of hospitals can thus be undermined by the complexity, long timeframes and multiple iterations involved in care pathway development.

27

In our analysis of the programming of hospitals and the related issues of process improvement and capacity optimization, we have, therefore, adopted a reverse engineering approach to care pathways. This involves three steps: 1) gathering, combining, validating and making consistent all the available patient data, making it possible to reproduce the patient’s journey by replaying all events per patient per disease/diagnosis in sequence; 2) producing multiyear capacity utilization patterns per facility (inpatient and outpatient departments, the OR complex, intensive care, emergency room, labs, radiology, etc.); and 3) applying the Pareto principle (the 80–20 rule) to the analysis of patient flows at a diagnosis/disease level, restricting the scope of the pathway analysis to a manageable set of the most important diseases/diagnoses. Once valid and consistent data are available, capacity utilization over time can be analyzed at different levels of granularity, ranging from specific rooms/facilities to individual specializations, to clusters of specializations with interchangeable facilities and, finally, at the level of the hospital as a whole. This analysis takes into account the need for differentiation. Thus, certain diagnoses and treatments (for example, in clinical neurophysiology), cardiac stress tests or urodynamic testing, ophthalmology laser treatment, and so forth need specific rooms. Specializations such as ENT, ophthalmology and urology need specially equipped outpatient departments. Other specializations can use relatively generic outpatient units; for instance, the cluster of surgery, orthopedics and plastic surgery can use interchangeable outpatient units, as can the cluster of cardiology and pulmonology. Once past utilization patterns are clear, scenarios based on simulations using real patient flow data can be developed to estimate future capacity requirements. Prior to conducting this kind of utilization analysis, one Dutch hospital, for instance, had estimated that it needed 290 outpatient units, ten operating rooms and 450 beds. The utilization analysis of the outpatient departments showed that the number of simultaneous appointments at the outpatient departments had never exceeded 177 and that at 99Æ% of the measurement points a maximum of 144 simultaneous appointments had been observed (the measurement points were one-minute-intervals during working hours on all workdays over a period of three years). Similar findings for the operating rooms and the inpatient departments led to a downward revision of the total capacity requirement to 150–170 outpatient units, eight operating rooms and 325–350 beds, suggesting a reduction in the total built area of more than 25Æ%. Utilization analysis is thus an effective tool for determining the capacity required per facility and for identifying opportunities for capacity optimization. The possible capacity optimization identified by these analyses does not factor in the effect of process improvements, but the last step of the analysis, the analysis of patient flows per diagnosis/disease (the care pathways), does just that. Patient flow analysis utilizes the same data set as capacity utilization analysis, but views it from the perspective of individual diagnoses. However, because of the very large number of diseases treated at a typical hospital, analyzing all of them is not feasible. We have found that the relationship between the costs and treatment volume of a typical hospital and the number of diseases treated follows the Pareto principle. In other words, approximately 20Æ% of all the diseases treated account for approximately 80Æ% of the volume, revenues, costs and capacity utilization at a typical hospital. Specifically, this corresponds to 300 of the approximately 1,500 diseases treated there. At the level of individual (sub) specializations, this corresponds to between five and 20 diseases for which the patient flows and pathways need to be analyzed, and the analysis of patient flows for, say, eight diagnoses for cardiology and 12 for ENT is indeed more feasible than the analysis of all the treated diseases. When subdivided between subspecializations such as hematology, endocrinology and nephrology, infectious diseases, etc., the approximately 50 diagnoses that represent 80Æ% of the internal medicine volume are also manageable. The analysis of patient flows compares the actual patient journeys with best-practice care pathways. For instance, the ideal pathway for middle ear infections involves an outpa28

DESIGNING HOSPITALS

tient appointment, followed by diagnostics, treatment (antibiotics or inpatient admission and surgery to insert tubes) and a follow-up outpatient appointment — four to five steps in all. The more uniform and compact the processes are, the more efficient is the capacity utilization. Patient flow analysis in combination with best-practice care pathways provides insight into the quality of the care delivered (encompassing predictability, effectiveness, duration from diagnosis to cure, complications, readmissions, etc.) and into how the care pathways can be improved. The improvement might be achieved by elimination of certain steps or a change in their sequence, shortening the duration of a step or the interval between steps, and monitoring compliance with best practice, among other ways. Given the enormous untapped potential of data-driven care pathway analysis to promote well-informed (de)centralization decisions, fact-based and objective composition and design choices, scenario planning and capacity and cost optimization, care pathway analysis is poised to become an essential component of the hospital design process.

THE DESIGN OF HOSPITALS: CARE PATHWAYS

29

Symbols and Color Scheme for Diagrams

Inpatient bed

Desk with chair

Lockable patient cabinet

Delivery bed

Bedside table

Washbasin

Toilet Built-inÆ/Æsofa bed Shower CradleÆ/Æincubator Workstation / computer on wheels

Cabinet with washbasin, alcohol dispenser and room for medical equipment storage

Cabinet with baby bath and changing table with room for medical equipment storage

Procedure-based trolley

Medical trolley

Walker

Curtain Medical pendant — examination light Medical stool

Chair Office desk with workstation

Extensible rooming-in chair Hospital bed head panel

30

DESIGNING HOSPITALS

Department

Functional area

Reception desk Public area Waiting area

Examination room Consultation room Outpatient department

Family area Office area Logistical and medical supply area

Hot floor and advanced diagnostic and treatment facilities

Treatment area

Sluice

Operating room

Logistical and medical supply areaÆ/Æinstruments preparation room

HoldingÆ/Æpreparation and recovery area

Operating room plenum

Family area

Instruments preparation room plenum

Staff facilities and office area

Generic inpatient department

Generic patient stay area

Ensuite bathroom

Resuscitation area

Nurses’ office

Medical staff area

Logistical and medical supply area

Rooming-in area

Specialized patient stay area Sluice

Specialized inpatient department

Medical intervention area Rooming-in area Nurses’ officeÆ/Æsupervising post Logistical and medical supply area

31

GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Processes and Spaces: the Example of the Maternity Department The way hospitals organize their care delivery processes determines the types and number of spaces they need as well as how these spaces are related. The converse is just as true: once these spaces have been built in a specific configuration, they effectively dictate the care delivery processes. The architects who design them need, therefore, to have a basic knowledge of these processes and the various care delivery options. This chapter illustrates the interrelationship between processes and spaces using the example of a relatively autonomous part of the hospital shielded off from the other areas and, for security reasons, often also from the outside world: the maternity department. Women over 14 years of age are reported to have more frequent contacts with the medical world than men do, and in American households, at least, they make most of the healthcare-related decisions. The more women are satisfied with a hospital, the likelier it is that they (and their families) will choose it again.46 Thus, many hospitals are paying particular attention to maternity units, given their central role in one of the rare hospital experiences associated with a (usually) happy event, namely, giving birth. Maternity units can be planned in a variety of ways but must respect a set of basic principles. The British Department of Health stipulates: ‘Whatever the setting and model of care, the main objective is to provide for the safe care of both mother and baby in a comfortable, relaxing environment that facilitates what is a normal physiological process, enabling self-management in privacy whenever possible, and enhances the family’s enjoyment of an important life event.’47 Guaranteeing security is one of the essential requirements for the maternity unit: all visitors need to be monitored, which calls for a limited number of manned entrances and makes this unit function as a separate island. ‘A robust and reliable baby security system should be enforced, such as baby tagging, closed-circuit television, alarmed mattresses.’48 Patients, Visitors and Staff Pregnant women, even when in labor, are not ill and should not be treated as patients. The only reason for them to go to the hospital is to have access to a safe and secure environment where the medical expertise and technology is at hand to deal with potential complications. Even in developed countries with a long tradition of delivery at home, like the Netherlands, women are more and more abandoning this practice due to an increasing awareness of the potential risks, especially if travel becomes necessary during labor.49 Apart from the mother and baby, maternity units need to accommodate visits by family, friends and relatives. Some maternity units at hospitals are supervised and run by midwives; medical specialists and nurses are responsible for others.

Delivery suite, HAGA Hospital, MVSA, The Hague, the Netherlands, 2016. The maternity ward incorporates results of evidence-based design research such as the view on outside greenery. 32

DESIGNING HOSPITALS

Antrim Maternity Hospital, RPP Architects, Belfast, UK, 2011. The refurbishment of the maternity wards made use of bright spaces and wooden cladding for part of the walls.

Spaces Maternity units, which consist of specific delivery rooms (or suites) and regular patient rooms for postnatal care, are increasingly designed as normal, home- or hotel-like settings. ‘Attendance at an antenatal clinic is often a woman’s first introduction to a healthcare facility. The suite should appear attractive and user-friendly, with a quiet, relaxed atmosphere that will maintain the woman’s confidence and dignity. The partner, friends, or other family members, including children, may accompany her. Waiting areas should be planned with this in mind, with access to play areas, drinking water and WCs. Wall decor should be non-clinical in nature and not adorned with medical diagrams’, thus contributing to a ‘welcoming and informal atmosphere’.50 The maternity units also accommodate spaces for pregnancy assessment and acute consultations, preferably in a different wing than the delivery rooms and postnatal patient rooms because of the often stressful nature of the consultations. These are equipped with consultation and examination rooms, an ultrasound room or a mobile ultrasound unit and waiting areas. Delivery suites are the heart of the maternity unit, a kind of substitute home — the natural setting for the natural event of birth. ‘The environment should be as non-clinical as possible with a comfortable, non-institutional ambience and should enable self-management in privacy. In all units, rooms should be designed to give women choice and control over their labor and birth, to normalize the process and welcome family participation.’51 These recommendations are generally accepted. For example, Wischer states that rather than organizing delivery suites in a linear sequence of steps, the various functions in a delivery suite should be integrated, allowing a home-like setting; in particular, place for the family should not be forgotten.52 In case of complications, operating rooms and facilities for recovery and child resuscitation are needed. Even in the obstetric surgery room, proper ambiance is essential; for ‘women often remain conscious during a Caesarean section and may be accompanied by a partner. The color scheme and lighting should therefore promote a relaxing atmosphere, but the lighting should not compromise clinical functionality.’53 Maternity units vary greatly in size and technological sophistication. Some of the first models were segmented along the distinct stages of birth — single or shared patient rooms during labor and for postnatal recovery, delivery suites for delivery and operating rooms for surgical intervention in case of complications or for (planned) Caesarean sections and the neonatal unit for ill newborns — and clustered each segment in specific areas of the maternity unit (or outside the unit in the case of the operating rooms). 33

Maternity d

M

Single/ shared patient room ( postnatal recovery)

Caesarian sections and other surgical interventions)

acute Caesarian sections and other surgical interventions)

the normal delivery process and postnatal recovery; room eq uipped for most non- surgical interventions) Neonatal unit ( premature and ill newborns)

Neonatal unit ( premature and ill newborns) Hom e

Single/ shared patient room

Deliv ery room ( patient stay limited to duration of delivery)

Single/ shared patient room ( postnatal recovery)

Operating room ( planned and acute Caesarian sections and other surgical interventions)

Neonatal unit ( premature and ill newborns) Hom e

B

Hom ematernity Delivery process and department spaces

C

A The fragmentation of the delivery process across different specially designated areas Single room adversely impacts quality of care and patient m aternity suite Operating ( SRM) experience (due to multiple transfers, roomlack ( patient stays for ( planned and the privacy, entire duration of and loss of control). of pain acute the normal delivery B The single-room maternity suiteCaesarian eliminates process and sections and postnatal recovery; surgical the forfortransfers (except for other acute surgical roomneed eq uipped interventions) most non- surgical interventions), but increases hospital costs interventions) (overdimensioning and underutilization). Neonatal C This model combines the positive aspects of unit ( premature the previous two models, enabling patient-friendand ill newborns) ly and cost-effective processes. The stages of delivery requiring specialized medical care and Hom e intervention take place in a high-tech environment (delivery suite), while postnatal recovery takes place in a relatively standard ward. Hom e

Maternity suite

Maternity suite ( postnatal recovery)

Neonatal unit ( premature and ill newborns) Hom e

DESIGNING HOSPITALS

Operating room ( planned and acute Caesarian sections and other surgical interventions)

Integrated neonatal and m aternity departm ent

Maternity departm ent

Single patient room

Integrated neonatal and m aternity departm ent

Operating room ( planned and acute Caesarian sections and other surgical interventions)

Hom e

Maternity suite

Deliv ery suite ( incl. dilation, delivery, 24- 48 hours postnatal recovery)

Maternity suite ( postnatal recovery)

Operating room ( planned and acute Caesarian sections and other surgical interventions)

Neonatal unit ( premature and ill newborns) Hom e

Hom e

A

34

Single room m aternity suite ( SRM) ( patient stays for the entire duration of the normal delivery process and postnatal recovery; room eq uipped for most non- surgical interventions) Neonatal unit ( premature and ill newborns)

Deliv ery suite ( incl. dilation, delivery, 24- 48 hours postnatal recovery)

C

Single patient room

Maternity departm ent

Maternity departm ent

Lab or room

Hom e

Integrated neonatal and m aternity departm ent

B

Hom e

Hom e

C

Newer models of Hom birth and neonatal care focus on reducing the number of transfers e and handovers a pregnant woman is subjected to during the delivery process and on Maternity enhancing the patient experience. One such model advocates maternity rooms where all suite processes related to giving birth (including recovery) could take place, from admission to discharge (excluding, of course, transfer to and from the operating block in case of compliDeliv ery suite cations or delivery, a scheduled Caesarean section). These rooms are called ‘single-room maternity ( incl. dilation, 24- 48 hours postnatal Operating recovery) room (SRM) suites’. Although this model a great step toward patient-centered care, ( plannedrepresented and acute it has proved to be quite expensive. Each SRM suite needs to be fully equipped not only Caesarian sections and Maternity suite for every stage of the normal delivery other surgical process, but also with additional equipment need( postnatal recovery) interventions) ed in case of complications. Most of the equipment needs to be permanently installed in Neonatal each SRM suite, with a limited number of mobile devices stored away and brought in when unit ( premature needed, requiring the SRM suite to be quite large. As the mother and child would occupy and ill newborns) for the whole length of their stay, most of the devices and space would these large suites be structurally underutilized. The consequence of large SRM suites was that the maternity Hom e department covered a large area, with the processes and medical teams spread farther apart than before. This could lead to fragmentation of processes and increased complexity in coordination between teams. The time required for teams to get to a suite in case of complications or to transport the mother to the operating block increased as well. Another issue was that, due to a lack of differentiation between the delivery and postnatal recovery areas, and the principle of zero transfers, the sorrow caused by traumatic complications, some involving death, could be the dominant mood right next door to a normal delivery with its atmosphere of celebration. This discordant mix of emotions would be detrimental to the experience of both these patients. The most recent models of care combine positive aspects of both the SRM suite and the old model with its segmented labor rooms, delivery suites and recovery rooms. The labor and longer-term recovery processes take place at home or in a maternity suite in a home-like setting, and the dilation, delivery and post-delivery recovery — typically lasting 24–48 hours — take place in a specialized, high-tech delivery suite. Quite often, both the delivery suite and the maternity suite offer rooming-in facilities for the mother’s partner. One variant involves the integration of the neonatology unit with the maternity unit, with neonatology suites (analogous to maternity suites) for the ill newborn. Unlike the traditional neonatology department (with multiple babies in incubators in one large room), this model involves one suite per baby, equipped not only with an incubator and other necessary equipment for supporting and monitoring the vital functions of the baby, but also with a normal inpatient bed for the mother. Resuscitation equipment is either mobile or integrated in the suite. An ill mother and a healthy baby stay in the maternity suite, a healthy

0, 9 m

0, 9 m 1, 2 m

1, 2 m

1, 2 m

4

4

1, 2 m

Maternity/neonatology suite with typical components: rooming-in area[II.3 (green), 2 - 1]patient area (yellow), medical staff area (brown), patient bathroom (blue)

0, 9 m

[II.3 2 - 1][II.3 2 - 1]

(and recovering mother) and an ill baby stay in the neonatology suite, and an ill mother and an ill baby (which is a relatively rare situation) stay as long as it takes for them to get back to health in a delivery suite, as the latter is fully equipped to deal with this eventuality. Integrating the neonatology department with the maternity department represents a major shift in the configuration of the hospital from a spatial and organizational perspective. By minimizing the chance of separation of mother and child (and the mother’s partner), the focus of this model is on patient participation in the care processes. The ability to make decisions, influence the environment and witness and understand medical procedures contributes to the physical and mental well-being of the patient. For example, if the baby requires resuscitation, intubation or other life-saving medical interventions, it is best to perform them in the presence of the parents. Some hospitals separate the baby resuscitation room from the delivery suite. However, in case of death or grievous or lasting injuries, it is important for the parents to know that no effort was spared to minimize injuries or save the life of the baby, since this knowledge can help them in their grieving process.

1, 2 m

0, 9 m

1, 2 m

0, 9 m

0, 9 m

4

Layouts of maternity/neonatology[II.3 suite 2 - 2]

[II.3 2 - 2]

A Composition when mother is hospitalized: the patient bed is positioned under the hospital bed head panel and the cradle is placed next to it; rooming-in for the mother’s partner is provided [II.3 2 - 2] on an extensible chair. B Composition when baby is hospitalized: the cradle is placed under the hospital bed head panel and the mother (if healthy) sleeps on a patient bed next to it; rooming-in for the mother’s partner is sometimes provided on an extensible chair. A

A

A

B

B

B PROCESSES AND SPACES

35

[II.3 3 - 1]

0, 9 m

0, 9 m

0, 6 m

The maternity unit is evolving from a process-oriented and specialty-centric facility to one focused on patient- and family-centered care. This evolution is occurring in other areas, too, and hospital design must allow for many changes — in the number, type and configuration of different functions and in medical technology and processes, as well as in cultural demands and economic restrictions — throughout the lifespan of the building, without the need for significant constructional adaptations. Kees de Wit and Laura Bulau contributed to this chapter. 1, 2 m

1, 2 m

1, 2 m

0, 6 m

Bab y resuscitation area with b ab y resuscitation tab le

0, 9 m

1, 2 m

0, 9 m

0, 9 m

1, 2 m

1, 2 m

1, 2 m

1, 2 m

Bab y resuscitation area with b ab y resuscitation tab le

1, 2 m

1, 2 m

0, 9 m

[II.3 3 - 2]

Delivery suite with typical components: roomingin area (green), patient area (yellow), medical staff area (brown), baby resuscitation area (pink), patient bathroom (blue)

Bab y resuscitation area with b ab y resuscitation tab le

A A

Layout options for the delivery suite A Composition including the baby resuscitation area inside the suite: the delivery room has sufficient space for the resuscitation table, enabling resuscitation, when needed, in the presence of the parent(s). The disadvantage of this option is Bab y resuscitation area with the need for extra space (additional investment b ab y resuscitation tab le and operating costs). B Composition A with the baby resuscitation area in a separate room: the resuscitation of the baby takes place in a separate room, enabling use of one resuscitation facility for multiple delivery suites. The disadvantage of this option is that resuscitation happens out of sight of the parents.

B Bab y resuscitation area with b ab y resuscitation tab les

B 36

DESIGNING HOSPITALS

COR WAGENAAR

Evidence-Based Design for Healing Environments

Akershus University Hospital, Oslo, Norway, C. F. Møller Architects, 2008. Art facilitates wayfinding and helps to provide identity.

What if every aspect of the hospital were to elicit perfectly calibrated and expected (and mostly pleasant!) experiences and feelings in all its users? If it were transformed into a building that knows all our needs, takes care of us, monitors everything we do and predicts what we will need next, making us feel as comfortable as possible? If this happens, evidence-based design will surely have made a contribution to it, for one may plausibly argue that it is on the way to offering scientifically valid architectural solutions that accommodate all our needs. Evidence-based design is a relatively recent phenomenon. In 1984, Roger Ulrich published an article that sparked its rise to prominence, and by now very few hospitals are being designed that do not pay at least lip service to it. Ulrich convincingly demonstrated how the views from a patient’s room window affected health outcomes.54 Patients who were able to look at green, natural scenery used less pain medication, could leave hospital sooner and were much more positive about the time they spent there than patients who had nothing but a brick wall to stare at. To a large extent, the views from patients’ rooms are determined by decisions made during the design phase of the building. By implication, design influenced health, and it did so in a way that expanded the well-established repertory of architectural and urban effects on hygienic conditions. Evidence-based design illustrates the now generally accepted fact that patients’ personal experiences and emotions have a direct influence on their healing process, further heightening our awareness of the close link between mind (feelings, experiences, perceptions) and body (medical outcomes that can be clearly identified and measured). The enthusiastic attention accorded to this link has even been described as ‘something like a religious revival’.55 In 2003, Kirk Hamilton, Associate Director of the Center for Health Design and Professor of Architecture at Texas A&M University in College Station, stated that evidence-based designers ‘make decisions, together with an informed client, on the basis of the best available information from research and project evaluations’.56 The Center for Health Design used a similar definition: ‘Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.’57 Since these outcomes directly or indirectly impact health, creating a healing environment can be seen as a ‘complementary treatment modality’.58 Morris A. Stein, principal of HKS, a firm that specializes in hospital architecture, claims that the ‘(…) design of the experience is equal to, if not more important than the design for accommodating the product technology’.59 The aspiration to base design on science is hardly new: as the next chapter shows, the very first hospitals that were built with the aim of healing people nurtured this ambition. 37

Nor is the appeal to the natural sciences as the only reliable source of valid knowledge, since that, too, harks back to the 18th century. What distinguishes evidence-based design is its focus on actually measuring the effects and the health outcomes of healthcare design on individuals as well as on groups of patients. How does evidence-based design research work? A typical case would select a specific area in a hospital, say, waiting rooms, and identify the people who use them. The main goal is to assess the way they are affected by the environment. That explains why environmental psychology played a prominent role in the first phase of its development. By now, Hamilton contends, ‘(…) there are an almost endless number of potential sources of information that are useful for evidence-based planning’, among them information technology, logistics, food service and performance improvement.60 Actually, the wide range of disciplines engaged in research on this subject creates its own problems, as Fiona de Vos, a Dutch evidence-based design expert, has observed: ‘Despite the different and important contributions of various fields, there seems to be very little mutual awareness among the different professions of each other’s work, resulting in an inefficient use of available data and knowledge.’61 Most research projects on the various hospital areas are comparative in nature. The way people react to the physical, spatial and also social aspects of these areas can be assessed using various methods, ranging from patient questionnaires to an analysis of their health statistics. Ideally, various design solutions can be identified; in practice, comparative research between them is most often limited to one aspect. Groups of patients with the same characteristics (age, gender, education, type of disease, type of therapy) can be found in different hospitals that feature a wide range of design solutions in the spaces they use. In principle, differences in the findings of the research may be attributed to the qualities of the architectural aspects that have been singled out, although the number of variables in any environment can complicate studies. A group of patients in one hospital can be an ideal target for research if they move to a new building or redesigned part of an existing one, allowing scientists to compare the effects of the changes in a post-occupancy evaluation. Stress is seen as the single most important factor affecting health conditions, stress factors including ‘the anxiety-inducing uncertainty of waiting, the poor acoustics produced by easy-clean low-maintenance surfaces, the smells, the harsh lighting, the difficulty of finding your way around a maze of impersonal corridors and the plethora of signs and scrappy notices.’62 Five major areas of potential stress reduction have been identified: connection to nature, the patient’s ability to make choices, social support, pleasant diversion and the elimination of environmental stressors.63 In all these areas, design may help. As Charles Jencks has noted, the placebo effect may also play a role in the result of design intervention.64 In addition to stress reduction patient safety and staff satisfaction are concerns as well. A few examples may illustrate research outcomes underlying evidence-based design. An analysis of the so-called ‘nouveau waiting area’ started with three hypotheses: it was expected to provide higher levels of patient satisfaction by putting patients in a better mood and thus produce a positive evaluation of specific design features. The most important conclusion was that ‘(…) the therapeutic impact of the nouveau environment is demonstrated not only by its relationship with decreasing self-reported stress but also by its associations with increasing pulse rate. This increase is entirely in accord with the appraisal of that environment as having a greater arousing potential.’ Thus, proper design not only reduced stress but also its equally debilitating counterpart: under-stimulation. In contrast, ‘The commonly communicated message of many traditional hospital designs is one of sterility and passivity.’65 An analysis of the use of color in Great Britain’s National Health Service hospitals revealed that color preferences and the experience of color harmonies go beyond the realm of personal taste. Whites and pale colors universally signified hygiene and cleanliness. Orange hues, it was discovered, should be avoided in dermatology departments but are very popular in maternity wards, where yellows, it turns out, should be avoided because they 38

DESIGNING HOSPITALS

Akershus University Hospital. The use of natural materials helps to soften the external appearance of the hospital.

hinder diagnostics. Blues and greens suggested calm but might cause depression in mental wards. In the cardiology department, blue should not be used because it made the diagnosis of patients more difficult.66 Moreover, the experience of color can be affected by cultural background: black represents death in much of the Western world, while white is the equivalent in Japan, and red is an auspicious color for the Chinese. Other factors can also come into play. Research carried out at Texas A&M University concluded that most children preferred blue and green hues and disliked whites; and girls were found to be more favorable toward reds and purples than boys were.67 Further, the use of greenery in hospitals, access to greenery inside and outside it, views of nature and a very strong preference for single-patient rooms have become staples of evidence-based design. Applying guidelines like these does not have to be limited to new buildings. Easy-to-implement suggestions that do not require major construction work include: hand-washing dispensers at each bedside, HEPA filters to improve air quality, ceiling-mounted patient lifts (reducing the risk of nurse injury while moving patients), noise reduction, high-performance sound-absorbing ceiling tiles, the option of music as a soothing distraction, artwork and virtual reality images and, finally, a clear wayfinding system. These measures should be supplemented by the provision of single-patient rooms, adequate spaces for families to stay overnight, rooms adaptable to the needs of acute care (to reduce the need to move patients to other departments), larger bathrooms with double-door access (to prevent fall accidents) and decentralized nursing stations.68 Single rooms of increased size with bigger windows might have a positive effect as well.69 Several special certificates have been created for hospitals that incorporate evidence-based principles or nominations, for instance the Canadian ‘Green Hospital of the Year’ award for use of greenery. Is it economically feasible to invest in architectural interventions inspired by evidencebased design? In order to answer this question, numerous post-occupancy evaluations have been carried out. The original so-called ‘Fable’ hospital, an initiative in 2004 to present an imaginary amalgam of innovations in hospital design, respected evidence-based guidelines, and its creators claimed that the investment in it could be earned back in a year. Fable 2.0, a virtual 300-bed institution that replaced a 50-year-old facility, was presented in 2011. It used more conservative calculations of possible savings and envisaged a period of three years to break even. Investments that increase a hospital’s performance by enhancing the patients’ experience — which has positive effects on their healing processes — may be expensive, but there may also be a ‘link between satisfied patients and profits’.70 EVIDENCE-BASED DESIGN FOR HEALING ENVIRONMENTS

39

Texas A&M University’s Center for Health Systems & Design, a joint venture of the Colleges of Medicine and Architecture, developed into the most influential institution focusing on evidence-based design. Research findings are published in HERD (Health Environments Research & Design) as the most prominent journal and Journal of Healthcare Design, the Evidence-based Design Journal and World Health Design. Scientists in disciplines unrelated to design have also entered the field, with findings published in the Journal of Environmental Psychology, The TQM Journal and Environment and Behavior. Architects may acquire Evidence-based Design Accreditation and Certification (EDAC), a specialist training in evidence-based design. Even though Ulrich’s findings supported claims commonly voiced in the world of architects — that buildings can have a positive effect on medical outcomes — evidence-based design has remained a somewhat controversial phenomenon in the profession. Proponents of the discipline have thus turned their attention to hospital managers rather than designers. Moreover, only few practitioners of evidence-based design have been trained as architects; most of them have been environmental psychologists. Kirk Hamilton — one of the rare examples of a healthcare expert who combines the disciplines of architecture and that of evidence-based design — explains: ‘Science is the study of principles, laws, rules or structures that can be observed in a tangible existing reality, while design is the act of imagining something which does not yet exist.’71 Already in the very first issue of HERD, he addressed the need to bridge the gap between the two. He urged designers to acquire the skills needed to understand better the language of serious research. ‘For the most part (…) design professionals have minimal experience with serious research. As a result, members of the design community tend to be nervous about reading and understanding original research. They are unsure of their ability to understand academic language, much less to critically interpret the implications of research on their projects.’72 Just how applicable are the findings of evidence-based design? Analyzing how scientific evidence can inspire architecture (seen as a ‘knowledge formation system’), Ricardo Codinhoto addresses the ‘lack of clarity regarding cause and effect relationships between the built environment and health outcomes. In medical research experiments can be controlled to a larger extent in comparison to research about the built environment and health. (…) In addition, the number of variables and combinations that can influence health out-

Juliana Children’s Hospital, Haga Hospital, The Hague, the Netherlands, MVSA Architects, 2015. Daylight has substantial effects on people’s health and well-being. 40

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National Center for Tumor Diseases, Heidelberg, Germany, Behnisch Architekten, 2010. The atrium provides daylight and helps to make the building comprehensible for all its users.

comes is extremely large, making impossible the replication of tests.’ A further complication is ‘the depth (or lack of it) of the descriptions provided in scientific literature that investigates this phenomenon’, one problem being the difficulty of reducing architectural qualities to what can be described in writing: ‘words do not always convey the essence of visual and spatial phenomena.’73 Codinhoto concludes that ‘(…) design can never be based on external evidence but merely informed by it. This happens because the contextual condition inherent and unique to each design problem can never be replicated due to the amount of variables involved in designing a space.’74 In other words, scientific findings are crucial, but more is needed. Architecture is a profession continuously forced to reinvent itself, as it adjusts to a changing context in which elements that it used to consider part of its core business — construction, management, supervision at the building site and even programming — have been transferred to specialized disciplines for almost all large-scale projects. Whereas the scientific character of some of these — engineering, building technology — has always been taken for granted, the situation is very different with regard to design. Yet the fear that the fixed rules of evidence-based design are bound to make good architecture impossible is unfounded. And architectural cross-fertilization with other building types — for instance, the introduction of innovations from the world of office buildings and stores in healthcare buildings — can enhance the performance of a design.75 While designers may have a tendency to see themselves as creative geniuses, a notion that originated in the late 19th century, what is needed here is a rational approach.76 Despite the assumption of some of the advocates of evidence-based design, architecture cannot be reduced to the latter without destroying it; and despite the assumption of many designers that intuition and creativity mark an unbridgeable difference between the two, there are many other factors in play in architecture, and these represent a better foundation for arriving at a viable partnership with evidence-based design. Does evidence-based design indeed open up new perspectives for creating buildings that will accommodate us more satisfactorily than has ever been thought possible? Surely, it helps to make buildings more convenient, but will not turn its inhabitants into passive receptors of their environment. Quite the opposite: in the end, evidence-based design seeks to empower the patient, not the building.

EVIDENCE-BASED DESIGN FOR HEALING ENVIRONMENTS

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NOOR MENS

The Building Type and its Emergence In the next decades, the hospital as we know it today may very well become extinct, and the meaning of the term may change dramatically. This has happened many times in the past. This brief history of hospitals as a typology and its previous transformations will serve to highlight the exceptionally dynamic character of the building type.

Hôtel-Dieu, Tonnerre, France, 1293, floor plan. Conceived as a charitable institution for the poor, this type of hospital offered its inhabitants mainly a large hall filled with many beds. Healing patients was not the primary goal, and though medical doctors offered their services, they often could do little to cure patients.

Ospedale Maggiore, Milan, Italy, Filarete, 1456. A unique example of renaissance architecture, the Ospedale Maggiore was a civilian institution that challenged the quasi-monopoly of the church and became one of the first hospitals that paid attention to hygienic conditions. 42

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Hospitals as Charitable Institutions Why concentrate people suffering from disease in a single building? The belief that special facilities might benefit their health extends back to Antiquity. The Greeks had asklepieia, complexes consisting of various buildings with a temple as their nucleus. Nursing patients was one of their main objectives. The Romans introduced valetudinaria in order to treat sick and wounded soldiers and thereby to help preserve the military and economic power of the state. The goal of improving the health of the people who came to the asklepieia and the valetudinaria was eclipsed when Christians began to conceive of healthcare as a responsibility of the Church. In 325 AD the Council of Nicaea declared that every town should have some place to take care of the sick. This resulted in the creation of the xenodochium, a combination of the basilica — basically a church — and the valetudinaria. The council of Aix-la-Chapelle, in 816, urged the Church to create charitable institutions for the poor to offer them help. And that help was given by hospitals, which were closely linked to the Church. This explains the use of the French term hôtel-Dieu. The most famous was the Hôtel-Dieu in Paris. Architecturally, the most interesting one is in Beaune (1443–1451), which still exists but has long since ceased to care for the ill. In addition to this, there were monastic hospitals, for example in Tonnerre (1293) and Angers (1153). All of these places were charitable institutions helping the poor, not hospitals in today’s sense of the word. The rise of cities in the 13th century, first in Italy and Flanders, then elsewhere, stimulated the development of non-religious forms of healthcare. Brunelleschi’s Foundling Hospital in Florence is credited with being the building that ushered in Renaissance architecture, but its Milanese counterpart is better known.77 The Ospedale Maggiore, designed by the architect Antonio Averulino, known as Filarete, was founded in Milan in 1456 and replaced a number of smaller structures. The highly innovative Ospedale Maggiore is not only one of the first hospitals built according to the geometric design principles of the Renaissance; it also turned to secular medical doctors to expand the range of the hospital services beyond the limited scope of what the clergy could offer. Remarkably for that period,

Royal Hospital Chelsea, London, UK, Christopher Wren, 1682. Built for wounded navy officers, this hospital was initiated by the state, which hired one of the country’s most esteemed architects. Wren designed a spacious building with a large central court. Royal Naval Hospital, Greenwich, London, UK, Christopher Wren, 1694. In the wake of the Glorious Revolution of 1688, the rise of the empire also saw the continuous expansion of the navy and all its institutions. Royal Naval Hospital, Stonehouse near Plymouth, UK, Alexander Rovehead, 1764. One of the first pavilion hospitals, Rovehead’s design was an early example of what became the dominant hospital type in the 19th and early 20th centuries. Inselspital, Bern, Switzerland, Franz Beer, 1724. A characteristic example of a corridor hospital

Filarete even paid attention to the building’s hygienic conditions. In this period cities usually also took care of people suffering from contagious diseases, often erecting simple barracks for them outside the built-up areas in an effort to prevent further spread of the disease. In the 18th century, the state joined the churches and cities as a supporter of hospital construction. Viewing its population as one of the main pillars of its prosperity and military power, the state focused primarily on the construction of military hospitals, a strategy that recalls the thinking behind the Roman valetudinaria. The Chelsea Hospital in London (1682) and the Greenwich Royal Naval Hospital (1694), both designed by Sir Christopher Wren, paved the way for the pavilion hospital. The wings in the Naval Hospital were divided into two separate wards that were connected on two sides. Alexander Rovehead took a further step in his design for the Royal Naval Hospital at Stonehouse near Plymouth (built 1756–1764) by splitting the wings into separate pavilions. The courtyard was left open, facing the seaside. Civilian hospitals also increasingly became instruments of health policy at the local level. Unlike the military hospitals, they focused on the poor. In some cases, their inhabitants were obliged to work: rounding up idle paupers from the streets, these institutions served security and economic purposes as much as they dispensed charity. Within just a few decades, dozens of them were built, especially in the German-speaking countries, which is also where corridor hospitals first appeared. Even though the latter were usually relatively small, their design echoed that of other representative buildings. The Inselspital in Bern, Switzerland, was the first of this type. Designed by Franz Beer and built between 1718 and 1724, its wards were situated on either side of a long corridor. Open spaces gave this relatively small building, which could accommodate only 45 patients, a friendly, airy appearance.78 The Charité in Berlin, an institution meant to accommodate 200 patients, followed its example. Founded in 1727, it was much larger and based on an almost square floor plan. Here, the corridor ran around an open courtyard and connected the wards, which had ten to 12 beds each, on the outside. This model culminated in the Allgemeines Krankenhaus in Vienna, which was conceived by Joseph von Quarin, who worked there as a physician and who received assistance from the architect Josef Gerl in formulating the basic design principles. They opted to renovate an existing sanatorium, which was reconstructed to accommodate no fewer than 2,000 patients.79 43

Charité, Berlin, Germany, 1727. Originally a sanctuary for patients suffering of contagious diseases located outside the city’s border, it was soon transformed into a teaching hospital. Allgemeines Krankenhaus, Vienna, Austria, Josef Gerl, 1784. An early case of a large hospital made up of long buildings that form gardens. The patient rooms are situated on either side of a central corridor.

Hôtel-Dieu, Paris, France, mid-18th century (before the fire). After numerous extensions, the hospital had become a maze-like complex that crossed the Seine. Even so, its capacity fell short of the demand, resulting in overcrowding, abominable living conditions and a high mortality. 44

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During the Renaissance, scientists began to question the traditional ideas about medicine that reflected the Middle Age’s religious concepts of the divine order of the universe, and empirical research slowly increased. Teaching hospitals developed, which tried to educate their students in the field of human anatomy. The heart of most teaching hospitals was the anatomical theater. The term ‘theater’ is no coincidence: seats or benches were arranged in tiers, although in most anatomical theaters the students surrounded the stage on all sides. Here, students saw how doctors dissected corpses and examined the internal organs of the human body. The oldest, which still exists, was built in Padua in 1594. For centuries, dissection was the only way to find out how the human body works. Specimens of specific organs were prepared and stored in glass bottles, and ultimately the accumulated results often filled entire rooms. Rudolf Virchow, who worked at the Charité in Berlin, is credited with revolutionizing pathological anatomy in the mid-19th century, establishing this field as the vanguard of medical research. The Hospital as a ‘Machine à Guérir’ — A Healing Machine Well into the 18th century, hospitals were places of charity, not medical institutions in the modern sense. Only in the late 18th century did curing the ill become their primary task. Medical doctors were not expected to play a substantial role in hospitals. The latter developed into technologically advanced facilities designed to provide their patients with clean air. It was generally believed that diseases were caused by so-called miasma, harmful vapors. Statistical analysis and medical cartography — two important scientific innovations — showed the link between the frequency and severity of diseases, on the one hand, and the physical conditions of the patients’ living quarters, on the other. The Allgemeines Krankenhaus in Vienna (1784) was among the first to use technology to improve the supply of fresh air and to dispose of air that was thought to be contaminated by contact with the patients. Taking into account scientific views on miasma and inspired by the technologies developed in the mining industry to ensure that the miners were supplied with fresh air, French designers developed plans that can be seen as the origin of the hospital as a specific building type. This innovation took place in tumultuous times: Paris on the eve of the French Revolution. The aims of the architects and planners partly coincided with those of the revolutionaries: they wanted to abolish a society based on religion and superstition and replace it by a rational order based on the laws of nature. When the Paris Hôtel-Dieu burned down in 1772, the time was propitious for replacing it by a hospital that no longer had any connection with the Church. Since the conditions of the patients in the old build-

Design for the Hôtel-Dieu, Paris, France, Antoine Petit, 1774. After part of the hospital burned down, enlightened medical doctors and architects joined forces and produced a remarkable number of revolutionary hospital designs that identified healing people as the institution’s primary mission. Providing fresh air was the aim of most models, among them this circular ‘radial’ type.

Design for the Hôtel-Dieu, Paris, France, Bernard Poyet, 1785. An alternative ‘radial’ plan

ing had been disastrous, with the death rate running as high as 1 in 4.5, there was broad support for the introduction of new approaches. Between 1772 and 1788, more than 200 proposals were made. It was agreed that the buildings most likely to foster the recovery of patients would be based on recent advances in the natural sciences. They were soon labeled ‘machines à guérir’, healing machines, and were designed, above all, to provide abundant fresh air. In 1774, Antoine Petit presented a radial plan where each of the six spokes functioned as a kind of wind tunnel. In the center, Petit projected a round building topped by a coneshaped vent, a form he derived from a glass-making furnace that had been published in the Encyclopédie.80 Bernard Poyet, a state-employed architect, and Claude-Philibert Coquéau presented a radial plan for a colossal hospital on the Île des Cygnes, which they published in the Mémoire sur la nécessité de transférer et reconstruire l’Hôtel-Dieu de Paris (1785).81 The plan, which was structured like a large fan, had 16 wings and a total capacity of more than 5,000 beds. The ideas behind these circular ‘ventilators’, which were intended to be erected in natural surroundings outside the city, were challenged by other architects, who favored rectangular plans. The latter could more easily be incorporated in an urban environment, which is where the hospital was supposed to finds its clients: the urban poor. JeanBaptiste Le Roy, a physician who had been working on his own plans since 1773, asked the architect Charles-François Viel to give architectural form to his concept of separate pavilions. Viel designed a symmetrical pavilion hospital, in which 11 wards were arranged in parallel, on either side of a great court, with smaller courts in between them. The design was published in 1789 in Leroy’s Précis d’un ouvrage sur les hôpitaux, which contains one of the first explicit references to a building as a machine. According to Leroy, a hospital should be ‘une machine à traiter les malades’.82 In his report he referred to tents in a military camp and, in a gentler vein, the pavilions in the garden of Chateau Marly (1679), designed by Jules Hardouin Mansart. To ensure the constant flow of fresh air, the pavilions’ roofs took the form of mine shafts.83 The pavilion type was recommended by the committee of the Académie des Sciences and soon accepted as the ideal for the layout of hospitals. However, it would take more than 40 years before the first hospital of this type was realized. That was the Hôpital Lariboisière (1839–1854) by Martin-Pierre Gauthier, who was instructed to base his design on the recommendations of the committee of the Académie des Sciences.84 Lariboisière was an immediate success and it was published all over Europe and the United States. Why did it take so long for the recommendations of the above-mentioned committee to be realized? As before, innovations in military healthcare paved the way for the civilian sphere. During the Crimean War (1854–1856), the British army erected field hospitals that were made up of separate barracks. Florence Nightingale advocated this arrangement and explained its advantages in her Notes on Hospitals (1859). In England her efforts resulted in the realization of the Royal Herbert Military Hospital in Woolwich (1859–1871), designed by Douglas Galton, and the St. Thomas Hospital in London (1866–1871), designed by Henry Currey. Perhaps the most perfect pavilion hospital was the one erected in Paris, which opened its doors more than 100 years after the fatal fire of 1772. The new Hôtel-Dieu, designed by Emile Jacques Gilbert, was situated on the northside of the square in front of Nôtre-Dame Cathedral. The site was suggested by Georges-Eugène Haussmann, who was responsible for the urban reconstruction that gave Paris its famous boulevards. Starting at the end of the 19th century, most of the hospitals built in Europe and the United States adopted the pavilion system. This allowed light and fresh air to flood the patient wards, which, moreover, were often surrounded by lavish gardens. The pavilion system was exceptionally flexible: a hospital could start with a few pavilions and gradually expand by simply adding new ones. One of the first examples of the type in Germany was the Städtisches Krankenhaus am Friedrichshain in Berlin (1868–1874), designed by the architects Martin Gropius and Heino Schmieden. The Städtisches Krankenhaus in THE BUILDING TYPE AND ITS EMERGENCE

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Royal Herbert Military Hospital, Woolwich, UK, Douglas Galton, 1859–1864. Stretched pavilions that resemble a corridor hospital layout are separated by gardens and connected through a central corridor.

Design for the Hôtel-Dieu, Paris, France, JeanBaptiste Le Roy, Charles-François Viel, 1773. The alternative for the circular hospitals was the pavilion type which, already tested in England, became the dominant model.

St. Thomas Hospital, London, UK, Henry Currey, 1866–1871. A comb-like structure that combines a number of relatively large, multistoried pavilions. Hôtel-Dieu, Paris, Emile Jacques Gilbert, 1866–1876. This building replaced the medieval Hôtel-Dieu.

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Hôpital Lariboisière, Paris, France, Martin-Pierre Gauthier, 1839–1854. Many years after the conception of the pavilion hospital, this hospital represents the first important example that was actually built.

Städtisches Krankenhaus am Friedrichshain, Berlin, Germany, Martin Gropius and Heino Schmieden, 1868–1874. A typical example of a pavilion hospital in Germany, it was designed by two architects who began to specialize in hospital architecture.

Operating room in Brooklyn Navy Yard Hospital, New York, USA, ca. 1900. Only when hygienic measures and the invention of anesthesia transformed surgery, did the hospital develop spaces that were specific and could not be found anywhere else – the origin of what was later coined the ‘hot floor’.

Städtisches Krankenhaus, Hamburg-Eppendorf, Germany, Carl Johann Christian Zimmerman and Friedrich Ruppel, 1884–1889. This complex shows the limits of the pavilion type: the distances between the buildings become too large to run the facility effectively.

Hamburg-Eppendorf, built between 1884 and 1889 after a design by Carl Johann Christian Zimmermann and Friedrich Ruppel, consisted of more than 50 pavilions. The latter example brings up one of the major disadvantages of the system: at a certain point, when more pavilions are added, the distances between them and centralized facilities like the laundry and the kitchen can become too great for the institution to operate efficiently. Even though both the radial and the pavilion type had been conceived to fulfill functional requirements that were unique to hospitals, there was nothing specific about the latter’s interior spaces — hallways, rooms and offices. This began to change when surgery gained importance, enabled by Crawford W. Long’s introduction of ether as an anesthetic in 1846, and Ignaz Semmelweis’ demonstration, in 1847, of the crucial importance of hygienic measures. He showed that washing hands reduced mortality caused by puerperal fever to 1Æ%. Following Semmelweis’ lead, Joseph Lister began to experiment with carbolic acid in 1867 and demonstrated that it diminished the danger of infection. Hospitals housed the only facilities that could properly accommodate surgical procedures. Thus the operating theater became the first functional unit that could be found only in these buildings and nowhere else, as the example of Brooklyn Navy Yard Hospital demonstrates. Operating theaters were characterized by the use of large areas of glass, which allowed surgery to be performed in daylight; often, the glass walls faced north to eliminate direct sunlight and sharp shadows. Surgery also transformed the perception of the institution: ‘By the 20th century, for the first time in history the risks of going into hospital were less than receiving treatment outside its walls, primarily because hospital infections were being brought under some control.’85 The Hospital as a Medical Institution With the introduction of medical technology such as X-ray machines around 1897, hospitals developed into medical institutions. Thanks to their use it became possible for the first time to ‘see’ inside the living body. Such expensive equipment had to be used efficiently and needed trained staff, and within a few decades hospitals developed a monopoly on medical technology. Medicine achieved considerable progress in the 19th century and hospital typology changed. The discovery of bacteria by Louis Pasteur proved that polluted air was not the major problem it had long been thought to be. Therefore, there was no longer a compelling reason to construct hospitals as pavilions and more compact hospital typologies evolved. High-Rise Hospitals The most impressive of these compact types appeared in the United States. High-rise hospitals were a response to the ever-increasing scale of the pavilion type and, in American cities, the high cost of land. Major high-rise hospitals were the Columbia University Medical Center (Presbyterian Hospital), designed by James Gamble Rogers (1926–1930), and the Cornell Medical Center in New York (1933), designed by Coolidge, Shepley, Bulfinch and Abbott. In Europe, only a few high-rise hospitals were built before World War II. Paul Nelson designed a large health center for the French city of Lille, which combined a medical school, a clinic, a hospital, a nursing home for the elderly and an apartment building. The complex, inspired by the Presbyterian Hospital of Columbia University, was touted as a ‘health city’.86 It was never built, however, and was replaced by a project conceived by Jean Walter, who had made his name as the architect of the Beaujon Hospital in Clichy, Paris (1933–1935). Built between 1935 and 1953, Walter’s plan was characterized by a rigorous separation of internal traffic flows. This had logistical advantages and also affected the scale of the building, which, although immense, was divided into a number of wings that spread out from a central core. To lower costs and improve logistical efficiency, the Swedish architects Hjalmar Cederström and Gustav Birch-Lindgren developed a type that revolved around nursing units of 25 to 35 patients, with rooms accommodating one, two, four or six beds. These units were concentrated in an eight-story complex. Outpatient departments and THE BUILDING TYPE AND ITS EMERGENCE

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Cornell Medical Center, New York, New York, USA, Coolidge Shepley Bulfinch and Abbott, 1933. The opposite of the pavilion type, the highrise hospital developed in the United States is very compact. Since the discovery of bacteria, polluted air was no longer seen as the primary cause of diseases and the pavilion type was perceived as obsolete. Columbia University Medical Center (Presbyterian Hospital), New York, New York, USA, J. Gamble Rogers, 1930. This high-rise complex is one of New York’s iconic hospitals of the era.

Design for the Cité hospitalière, Lille, France, Paul Nelson, 1933, model view. This example of a large-scale, compact hospital celebrates modern medicine in a building that radiates a modern, rational atmosphere but remained unbuilt.

treatment areas were located in separate but parallel wings, which made it easy to connect them. The Södersjukhuset (1944), architecturally a more straightforward building, inspired similar projects in several European countries. The nursing unit could be repeated as many times as was needed to arrive at the desired number of beds. A similar development can be seen in the Bürgerspital in Basel, designed by Hermann Baur in 1937. Here, the nursing wards, which all together could accommodate 1,000 patients, consisted of 16-bed units, which were in turn divided into two six-bed and two two-bed rooms. There was a clear distinction between the nursing areas on the one hand, and the treatment, research, laboratory, administration and university areas, on the other. Exploiting the pleasant California climate, Erich Mendelsohn concentrated the patient rooms of his Maimonides Hospital in San Francisco in a high-rise wing with rooms that gave access to balconies. New Configurations T-Type, K-Type, H-Type Given the rapid post-war population growth, an unprecedented increase in the demand for hospitals ensued throughout Europe and the United States. Since demand was expected to keep growing, the need arose for a type of building that could be substantially expanded without creating logistical chaos.

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Hôpital Beaujon, Clichy, Paris, France, Jean Walter, Louis Plousey, Urbain Cassan, 1932–1935. This European version of the American high-rise compact hospital established Walter as a specialist in healthcare architecture.

Södersjukhuset, Stockholm, Sweden, Hjalmar Cederström and Gustav Birch-Lindgren, 1944. The architects’ main design principle was a clear distinction between the hot floor, the outpatient department and the patient wards; they are often credited for introducing the nursing unit. Bürgerspital, Basel, Switzerland, Hermann Baur, 1937–1946. An example of synthetic modernism, this is one of the first H-shaped hospitals.

Maimonides Hospital, San Francisco, California, USA, Erich Mendelsohn, 1946–1950. This hospital combines the open, sun-flooded architeture of California with the abstract architectural features of European modernism. THE BUILDING TYPE AND ITS EMERGENCE

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K-type hospital, Diakonessenhuis, Groningen, the Netherlands, Jan Piet Kloos, 1965 H-type hospital, Julianaziekenhuis, Terneuzen, the Netherlands, Jan Piet Kloos, 1954. This H-shaped composition offers a clear distinction between the main departments.

Franco-American Memorial Hospital, Saint-Lô, France, Paul Nelson, 1945–1954. This hospital is credited for introducing the Breitfuß model in Europe.

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Continuing the innovations made at the Södersjukhuset and the Bürgerspital, a number of ‘alphabet’ types were developed, such as the T- and the K-type.87 A simple version is the T-type, with the treatment areas in the vertical element. Jan Piet Kloos’ Diakonessenhuis in Groningen (1965) is an example of the K-type, with its characteristic bend in the patient wards, which since they face south, appear to embrace the sunlight. The H-type, where one of the parallel wings accommodates the treatment spaces and the other one the patient ward, was inspired by Swedish and Swiss examples. Often, the treatment areas are divided into an inpatient area for those staying overnight in the hospital and an outpatient department for those leaving soon after receiving treatment, each part accommodated in a separate wing. The separation of wings with different functions obviously facilitates future expansion, since construction work in one part of the institution would not automatically lead to problems in the others.88 From the late 1950s on, the Breitfuß or ‘wide foot’ model rose to prominence (also known as hôpital arbre, socle-tour or in Britain as a ‘matchbox on a muffin’, that is a tower on a podium.) The assumption that patient wards do not need to be constantly refurbished and reconstructed, whereas technological innovations make changes in the treatment areas almost routine, resulted in the combination of a stretched-out, low-rise building of at most three floors and a patient ward in the form of a high-rise tower or slab on top of it. Inventions in the building industry facilitated the construction of very deep ‘muffins’: ‘With the aid of air conditioning and deep-span frame structures it becomes possible to plan a hospital like a department store, in one continuous floor, occupying the whole of the site.’89 The Breitfuß — the German epithet became its informal name — was first developed in the United States, where it was introduced in a number of military hospitals before becoming the standard type for all hospitals for a considerable time. Gordon Bunshaft is credited with being among the first to explore its advantages — at the Fort Hamilton Veterans Hospital in Brooklyn, New York. In Europe, one of the first of this type was the Franco-American Memorial hospital at Saint-Lô (1945–1954), designed by Paul Nelson. An English example, inspired by the work of the Nuffield Provincial Trust’s Studies in the Function and Designs of Hospitals, is the Princess Margaret Hospital in Swindon, commissioned in 1953 and designed by Powell and Moya with Llewelyn-Davies Weeks.90 The expectation that the wards would shrink while the outpatient departments rapidly expanded called for types that could accommodate changes without expansion of their footprint. This led to a return to low-rise hospitals, since reconstruction was now seen as inevitable in all parts of the building including the patient wards. One of the first to explore the flexibility of low-rise structures was Hvidovre Hospital, Denmark. The reappearance of the low-rise types coincided with the emergence of counter-cultural criticism in the 1960s (which accused the high-rise hospital of representing an ‘authoritarian’ approach to medicine and called for patient-centered care) and structuralism in architecture. Ideally,

Princess Margaret Hospital, Swindon, UK, Powell and Moya with Llewelyn-Davies Weeks, 1953– 1966. In the 1950s, the Nuffield Trust in England advocated a scientific approach to hospital architecture, inspiring projects like this hospital.

Academic Medical Center (AMC), Amsterdam, the Netherlands, Architectengroep Duintjer with Dick van Mourik, 1981–1985. A striking example of structuralism, this hospital combines a permanent structure with semi-permanent and flexible elements, allowing processes of change.

the scale of hospital structures should be in harmony with the urban fabric of the area in which they are sited, but most new hospitals were built with a complete disregard for the local urban context. An example of a building that translates the structuralist approach often found in low-rise complexes into one built on a much vaster scale is the Academic Medical Center (AMC) in Amsterdam, completed between 1981 and 1985 to the design of Architectengroep Duintjer in cooperation with Dick van Mourik. The architects made a clear distinction between permanent parts (the concrete structure), semi-permanent components and elements that are likely to change regularly, thus emulating the growth and transformation of historical cities. Another quality that the building shares with historical cities is the distinction between private and public parts; the latter form a spacious combination of covered streets and squares which provide for urban functions like shopping. Comb structures and models that use an internal street to lend greater coherence to the complex also became quite popular. Other hospitals are organized around large halls, an early example of which is the Krankenhaus Neukölln, Berlin by Josef Paul Kleihues (1985–1986). The End of Hospital Typology? Typologies are based on the assumption that specific functions can best be accommodated in buildings designed specifically for them. The clarity inherent in this approach lost much of its appeal when rapidly growing hospital departments were located near departments that were expected eventually to need less space. A clever division into zones was one of the ways conceived to increase flexibility, along with the preference for oversized spaces, since that made it easier to adapt them to purposes other than the ones they were originally designed for. The idea was to overcome the limitations of customized buildings perfectly geared to their specific function — the essence of functionalist design — since they cause problems as soon as the functional requirements change.91 Recent research supports the view that small hospitals generate fewer logistical problems than large ones and that many hospital functions ought to be outsourced. One of the most widely accepted concepts among architects and hospital managers today is that of the core hospital, according to which only those spaces that are truly specific, that is, devoted to diagnosis and treatment, should be tailor-made, while all other parts can be designed on the model of other building types. The wards, for instance, can be designed as a hotel, and a considerable part of the outpatient department can be modeled on the kind of retail facilities that have both front and back offices. The next step could be to outsource all services that are not really needed on the site, such as the laundry, the kitchen, the laboratory, even part of the patient wards and the outpatient department. What remains is a ‘core hospital’. Thus, an entirely new hospital landscape may emerge in the future.

THE BUILDING TYPE AND ITS EMERGENCE

51

TOM GUTHKNECHT, PETER LUSCUERE, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Zoning and Traffic System All hospital buildings are compositions of distinctive functional zones tied together by their internal traffic structure and logistical layouts. Their organization is a crucial step in hospital planning. It is very difficult and sometimes virtually impossible to remedy mistakes made in this critical early planning phase. Zoning Although the so-called functional brief (space program) determines the functions and spaces that the building should accommodate, it typically does not specify the spatial configuration best suited to optimize its performance. Whereas a very large body of information exists regarding technical details and the functional requirements of the separate components, the development of simple and transparent global rules for benchmarking and continuous project control have been largely neglected over the past few decades. In 1987, Robert Wischer listed the various functional components in a virtual construction box which referred to the German industry norm DIN 13080, providing a fixed framework intended to avoid confusion. To date, however, virtually no resources have been made available that describe the hospital as a composite structure of diverse functions which derives its logic from the way it connects to other facilities, both medical and semi-professional within a healthcare network. Approaches range from concentration of comparable functional units (with one complex of operating rooms for the entire hospital, for instance) to organizing hospitals around specific patient groups (concentrating those suffering from cancer, for example, in one wing) and providing all the medical functions needed for their treatment, thus resulting in the dispersion of various operating rooms in different parts of the hospital. Deciding which solution is preferable is not a linear process and in many cases follows an unpredictable pattern. The complex interdependencies of a wide variety of issues create a ‘pattern of compromises’, as individual goals sometimes compete or even contradict each other. Once a decision has been made, however, the preservation of coherence in the planning and design process is as important as the use of the right planning tools and strategies. To maintain this continuity and protect strategic planning decisions remains one of the biggest challenges in the long-term design process of health facilities. In the latter half of the 20th century, most hospitals grew in an organic manner. The individual medical specialist was the key figure, with his or her personal study located adjacent to an examination room, which had its own waiting room. A secretary sat behind an elevated counter receiving patients, and this arrangement was repeated in accord with the number of specialists involved. This quite common set-up reflected the composition of the medical staff and its hierarchical differentiation. It also reflected the isolation of many specialists and the absence of a focus on patient-oriented care. Before the 1930s, most general hospitals housed just two departments: internal medicine and surgery. In the 1950s, maternity departments were added, and in the 1960s separate intensive care units were introduced. Since then, the number of specialties has grown steadily, while their internal organization and interrelations remains largely the same.92 This has led to a situation where increasing specialization does not yield a design approach conducive to interdisciplinary cooperation. In most hospitals the main functions are divided into four zones: (1) outpatient clinics and public areas; (2) the ‘hot floor’ with technology-based diagnostic facilities and treatment areas; (3) patient wards; and (4) logistical and back-office areas. While technical services are found throughout the building (and are particularly concentrated on the hot floor), all the very specialized technical areas have to be positioned in centralized locations at an early planning stage. It is worth considering the creation of one or two floors assigned only to technical services. Dedicating certain floors exclusively to technology separates traffic flows, facilitates maintenance and provides a far more efficient environment for the ongoing changes and functional adaptations characteristic of the hot floor.

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The distinction of functional zones led to the hospital building typologies of the 1950 and 1960s, such as the H- and T-types and the matchbox on a muffin (‘Breitfuß’), which were discussed in the previous chapter.93 Thanks to a better understanding of hospital hygiene, the functional requirements of the main zones can now take precedence over the distinctions into different types of diseases and categories of patients, and thus designs usually reflect an internal organization based entirely on medical functions. If services need to expand but cannot do so at their current location, new building structures are added, which may lead to a mishmash of permanent and temporary structures, obscuring the overall clarity of the zoning system. Traffic flows may get confused and, in the end, orientation within the hospital may become very difficult to establish — not only for visitors and patients, but also for staff. The necessity to integrate zones for growth (e.g. outpatient departments) with zones expected to diminish in size (often patient wards, since the average length of a stay in hospital is expected to decrease even further) adds to the organizational and visual confusion. In the last two decades, configurations have been rethought in terms of their logistical, economic, social and hygienic aspects. In many hospital refurbishments the original building typologies were not maintained when modifications and expansions took place, which caused considerable confusion. The principal impetus to fundamentally rethinking hospital composition, however, has been the need to promote closer cooperation between the various medical specialties. When multidisciplinary teams are needed, the layout of the building should facilitate their cooperation. For example, in some successful cases research scientists who formerly worked isolated from the rest of the hospital in a laboratory setting now convene regularly with the medical staff who treat the patients. In general, the spatial structure of a hospital can either enhance or frustrate translational interactions between the different groups involved. Out of this need for better integration, four alternative concepts (ill. p. 55) have emerged: (A) the theme model (which organizes medical specialties around the needs of the patients); (B) the center model (based on medical processes); (C) the three-flow model (distinguishing acute patients, outpatients and inpatients); and (D) the typological model (which sees the hospital as a composition of largely generic building types). The following are a few examples from the Netherlands:94 The theme model was first developed for university medical centers. These tend to be very large institutions with 1,000 beds or more. By defining subdivisions such as mother and child, oncology, etc., large-scale complexes can be divided into a number of quasi-separate hospitals which focus upon specific medical conditions; they remain connected to the other units. Sophisticated zoning within these usually multistory buildings ensures easy access to the medical functions they house — for example operating rooms and laboratories. An example of such an approach is found in the Groningen University Medical Center, where the hot floor is accommodated in a stretched-out central volume with spacious main streets on either side. Bridges across these streets lead to the patient wards, which offer inpatients a view of the surrounding urban tissue. The lower floors are reserved for outpatient clinics. People walking through the covered streets experience these clinics as separate buildings, each with its own medical departments. The result is a clearly understandable layout that is further enhanced by a very large entrance hall giving access to the main streets. An example of the center arrangement is the Orbis Hospital in Sittard, also in the Netherlands, where special attention has been paid to the redesign of medical processes. Flexibility and a viable real estate strategy are the key elements here, resulting in a composition of specific care and cure units. Three main areas — screening and diagnostics, consultation, and treatment and nursing — are complemented by knowledge centers that replace the private rooms of the medical staff and are intended to enhance multidisciplinary processes. The traffic routes of patients and staff are strictly separated. In the three-flow model, which differentiates between acute patients, outpatients and inpatients, the foci of attention are the patient traffic flows. With acute patients, fast and 53

effective intervention is the only thing that matters. In management terms: product is key. For inpatients, process is key: efficiency and operational excellence are the guiding principles. The (architectural) qualities of the environment support the medical processes and enhance personal experiences, which, in turn, have an influence on the medical outcomes. In outpatient departments, the patient is key: the processes are customer-oriented. This third system uses one entrance for both inpatients and outpatients. By locating the outpatient departments next to the entrance, the traffic they generate is limited to this area. Only inpatients (and those visiting them) need to enter the next zone, which accommodates the wards. This is followed by the hot floor which is out of bounds for visitors. Often, however, the hot floor is located between the patient wards and the outpatient departments, allowing close contact between the two zones where patients are treated. This solution presupposes that inpatients and visitors can cross the hot floor without getting mixed up in the traffic flows within that area. The typological model distinguishes four categories of spaces: the hot floor, the hotel, the office and the ‘factory’. Only the hot floor should be considered as specific to hospitals; it combines all intensive medical and technological areas — the operating rooms, the ICU/ CCU, etc. All the nursing areas can be integrated into wards which together operate as a hotel. And all office activities, including outpatient functions that do not require sophisticated technology, can be accommodated in wings that emulate normal office buildings. The factory contains technical support functions. The hot floor is the core, although it can be argued that several of its functions could just as well be outsourced to other medical facilities (depending upon the overall distribution model). All four arrangements have their pros and cons, often depending upon the project’s size, location and economic feasibility. Often, characteristics of several models are combined, resulting in hybrid arrangements. In all of them there is a distinct preference for generic components, limiting the parts that are specific to hospitals to the hot floor and some technical departments. The generic parts allow designers to borrow innovative ideas, for instance, from modern office buildings or, especially relevant here, from hotels. Traffic The distinction between functional zones is one of the primary features of the overall layout of hospitals. Another key factor is the allocation of traffic infrastructure (halls, interior streets, corridors, staircases, elevators), which is itself largely determined by the zoning plan. This brief discussion focuses almost exclusively upon people, without going into detail about the transportation of goods and services, which also requires an extensive infrastructure. Hospitals generate large volumes of internal traffic. To what extent they are veritable traffic machines is illustrated by Colin Buchanan, author of an influential study on traffic in post-war Europe, Traffic in Towns (1963), best known as the Buchanan Report. He referred to hospitals to justify the idea of banning through traffic in urban centers — if food trolleys don’t pass through operating rooms, why should cars that have no business being there clutter inner city streets?95 If the zoning plan is chaotic, traffic flows are bound to be chaotic as well, and very little can be done about it. Several distinct flows can be distinguished which, ideally, do not interfere with each other. Patients come in two categories: hospitalized inpatients and clients of the outpatient clinics, who often bring families and friends with them and who return home after diagnosis or treatment. The latter category generates the largest traffic flows, and one of the objectives of the zoning plan is to make sure these do not mix with the other flows, in particular those of the inpatient wards. A number of the inpatients are bedridden. Thus, if a patient has to be moved, then the nursing staff has to maneuver the bed from the patient’s room to the diagnostic or treatment areas. Only the inpatients themselves, their visitors and staff should have easy access to the patient wards. The medical staff often has its home base in the treatment areas and the outpatient clinics, and so does the nursing staff.

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Traffic routes are major determinants of a hospital’s patient-friendliness, efficiency and safety. They should be designed to give the medical staff easy access to the patients and to the necessary equipment. This will help ensure fast and safe procedures as well as eliminate clutter, creating a more private and non-frustrating medical experience for both patients and staff. Separating contaminated from ‘sterile’ (very clean) routes decreases the risk of contamination and infection; and the separation of patients according to specific treatment units helps avoid patient-to-patient cross-infection. Finally, grouping patients by the urgency of the required medical attention can eliminate unnecessary flow crossing — with patients in beds separated from ambulatory patients and all patients separated from logistical services — thereby improving efficiency and safety. Most hospital procedures occur according to fixed schedules, although in the acute medical unit (accident and emergency), which is characterized by the unpredictability of patient arrival and care requirements, this is not possible. Therefore, combining predictable and non-predictable patient flows results in the need to prioritize acute patients over non-acute ones, making the entire care process impossible to plan in any detail. From the point of view of the patient with a predictable care pathway, this situation means increased waiting time. From the point of view of the hospital, disturbances in scheduled medical procedures lead to an overall slow-down. Medical staff could thus become overbooked and overwhelmed with unanticipated patient care or, alternatively, be confronted with empty consultation hours. Separating predictable and non-predictable traffic flows supports the

A Inpatient wards

Inpatient wards

Hot floor Outpatient dept.

Inpatient wards

Hot floor Outpatient dept.

Pub lic area

Inpatient wards

Hot floor Pub lic area

Hot floor

Outpatient dept.

Pub lic area

Outpatient dept.

Log istical and medical supply area Mother and child center

Oncolog y center

Cardiovascular center

Hot floor

Inpatient wards

Inpatient wards

Other centers

B

Pub lic area

Outpatient dept.

Pub lic area

Outpatient dept.

Knowledg e center

Log istical and medical supply area

C Typical hospital configurations Inpatient wards

A The theme model divides an often largescale complex into subdivisions for specific medical conditions or patient groups. B The center model is organized around multidisciplinary medical processes, with strict separation of patient and staff traffic flows. C The three-flow model differentiates between acute patients, outpatients and inpatients; the focus is on patient traffic flows. D The typological model distinguishes four types of spaces: the ‘factory’ housing technical functions, the office, the hot floor (treatment areas) and the ‘hotel’ (patient ward).

Outpatient dept.

Hot floor

Pub lic area Emerg ency dept.

Log istical and medical supply area

D

Technical support functions

Outpatient dept.

Hot floor

Pub lic area Log istical and med. supply area Factory

Inpatient wards

Pub lic area

Log istical and medical supply area Office

Hot floor

Hotel

ZONING AND TRAFFIC SYSTEM

55

Overview of functional zones within the hospital and possible design approaches

Pub lic area 1 Entrance 2 Reception/ admission 3 Waiting areas

Customer-oriented Shopping mall design

Outpatient departm ent 1 Outpatient consultation and treatment 2 Pre- operative screening 3 Dialysis

Customer-oriented Shopping mall design

Hot floor w ith adv anced diagnostic and treatm ent facilities 1 Diagnostics: - Radiology - Nuclear imaging - Functional assessment - On- site laboratories and front offices ( sample collection)

Process-oriented Factory/high-tech design

2 Endoscopy 3 Emergency department 4 Operating rooms 5 Delivery rooms 6 Cardiac diagnosis and intervention 7 Radiological diagnosis and intervention 8 Radiotherapy

Inpatient departm ent 1 A dmission, discharge, transfer 2 Day treatment 3 Standard nursing wards 4 Specific recovery wards: - ICU/ MCU - CCU - Neonatology - Pediatrics - Psychiatry

56

continuity of medical processes and prevents interruptions and disturbances. Inpatient and outpatient areas require separation as well, as patients admitted to the hospital often suffer from more severe illnesses than the ones who require only outpatient and day treatment services. It is difficult to navigate a patient’s bed through a crowded corridor and the encounter between a bedridden patient and scheduled patients can be disconcerting. Thus, separating these types of patient flows will increase privacy and avoid embarrassing situations. Finally, the outpatient department usually functions eight hours a day, five days a week, with the result that during some parts of the day the area is empty and inpatients cannot use its facilities. In the evening, these areas become dark, deserted and disorienting spaces. Patient traffic can be separated by type of disease or by department (mother and child care, elderly care, oncology, operating rooms and associated care facilities, internal medicine, gastroenterology, neurology, rehabilitation and outpatient medical specialties). This allows for easy access to specialized consultation and treatment areas and supports a patient-centered approach. Separation by unit, inside a department, is sometimes recommended in the case of contagious patients to minimize contamination risks. Another reason for creating traffic separation is to make orientation within the hospital easier. This is important for both patients and staff, who can then navigate through a restricted, designated space without needing to traverse the entire facility.

PUBLIC SPACES

Outcome-oriented Factory/high-tech design

Customer-oriented Hotel design

Customer-oriented Hotel design

Logistical and m edical supply areas 1 Medical: - Pharmacy - Off- site laboratories - Instrument steriliz ation 2 Non- medical: - Food, linen, disposables - Housek eeping, cleaning - Waste disposal - Eq uipment maintenance - B uilding maintenance

3 Office facilities: - Work spaces - Meeting rooms and conference facilities - Education facilities 4 Staff facilities: - Changing areas - Relaxation areas - Overnight stay

Process-oriented Factory design

Process-oriented Warehouse design

Customer-oriented Office design

Customer-oriented Hotel design

To encourage interdisciplinary collaboration, multidisciplinary facilities now tend to be placed closer to the core of the hospital building, while the more independent facilities are located in the less intensively visited areas. Back-office areas, for example, require no direct contact with patients and in some cases can be entirely separated from the hospital building. Other activities that can be moved to the periphery are sterilization of instruments, waste disposal, reception and storage of medical equipment and other goods, individual study and research, food preparation, laundry and so forth. This disposition of the various functions makes it easier to separate staff flows from incoming and outgoing patient flows. Traffic through the hospital varies with the time of day and the particular area. Some important moments during the day are the arrival and departure times of staff members, the start and end of the outpatient department working hours and the changing of staff on duty in departments which are open round the clock. It is important to separate entrances for patients, medical staff and back-office staff in order to facilitate the co-existence of these daily rhythms. To this end, one can establish corridors destined exclusively for medical staff, an option which also helps promote collaboration between medical specialists by allowing them to meet informally. Of course, the advantages of creating many different access routes have to be counterbalanced by the need to satisfy safety and security requirements. Functional zoning and the establishment of different traffic flows turn some parts of the hospital into essentially public spaces. The division of the hospital into areas used by different categories of people determines the degree to which those areas can be considered to be public spaces. Entrance halls, shops, restaurants, most waiting areas and the main traffic arteries leading to the various departments have a public character, whereas access to the corridors and social spaces in the inpatient wards is restricted, and in the treatment areas only the medical staff and their patients are allowed. Acute patients frequently arrive by ambulance and need a separate entrance, which is often located near the emergency department. However, an increasing number of patients of all types arrive by ambulance today, many of them without an acute emergency status. Therefore, the ambulance access route must be planned in a manner which allows an efficient triage between general admissions by ambulance, on the one hand, and accident and other emergency room patients, on the other. Functional zoning and a clear distinction among traffic flows define the spatial composition of the hospital and form the backbone of its logistical organization. Clearly, the setting of the building, the size of the plot, and the possible ways of relating the hospital to its context are also major factors in determining the feasibility of various potential design solutions. A location in a dense urban setting may call for a high-rise hospital, which can be less convenient elsewhere, because it usually requires a construction grid that is uniform throughout the building, regardless of the functional requirements of the various departments.96 In some cases, it does make sense to replicate a design: floor plans, for example, and certain other parts of the various major units of the building. In principle, a series of identical hospitals can be imagined, but local particularities effectively limit the scope of standardization.

ZONING AND TRAFFIC SYSTEM

57

NOOR MENS

Arrival and Entrance

Kinder- und Herzzentrum, Innsbruck, Austria, Nickl & Partner Architekten, 2008. The modest but clearly recognizable entrance respects the scale of the building.

UCLA Outpatient Surgery and Medical Office Building, Santa Monica, USA, Michael W. Folonis Architects, 2012. Since most visitors arrive by car, the routes from the parking were carefully designed. The architects introduced a compact, automated car parking system.

Extension Kolding Hospital, Kolding, Denmark, Schmidt Hammer Lassen Architects with Creo Arkitekter, 2016. A generous walkway leads up to the main entrance. Health Boulevard Zaandam, the Netherlands, Mecanoo, 2017 (rendering). The health boulevard is a transition zone in a spatial as well as functional sense: it offers the urban qualities of an inner city street and is lined with shops related to healthcare. 58

PUBLIC SPACES

Ludwig Mies van der Rohe, one of the pioneers of the modern movement, is reported to have said that ‘hospitals belong in the best and most healthful sections of the city. They belong in parks where the air is purest, away from the smoke screens that smog our cities (…) Hospital planning must be of a piece with city planning.’97 The hospital has even been described as a public institution which defines the city in the same way cathedrals did in the past!98 It is not hard to see that there is an intimate connection between hospital architecture and urban planning. Large building complexes are often thought of as cities in their own right, posing urban planning issues. The size of traditional large-scale medical facilities marks the areas they occupy as distinct sectors within the larger urban tissue. Like railway stations and department stores, they serve a public function and are open 24 hours a day.99 Which parts of the city are best suited to accommodate hospitals depends largely on their size and their particular array of medical specialties, which is determined by the models of the distribution of medical services (cf. ‘Distribution of Healthcare Facilities’, pp. 23–26). For large complexes, easy accessibility is crucial. Since the 1940s, planners have preferred to locate them near main traffic arteries. Now, reintegration in an urban setting is increasingly seen as important, since it may help break down the physical, mental and functional barriers between the medical machine and its clientele. The destruction of historic inner city hospitals can be disruptive, disturbing the ‘evolving role of memory, place and sustainability’.100 As its link with the outside world, the entrance is a crucial part of the hospital. The current ambition to ‘urbanize’ the hospital and break down the barriers between the world inside and outside is, however, not likely to result in the dismantling of the existing borders. Except for the inpatients, everybody using a hospital has to come from outside, either on a regular basis (people working or studying there) or occasionally, because they

need treatment in outpatient departments. Consequently, hospitals have a tendency to become traffic hubs, whose functioning is determined by numerous factors, such as their sites (in city centers, at the periphery or in natural surroundings), the size of the region from which they attract their patients (which tends to become larger the more specialized a hospital is) and the latter’s preferred mode of transport. Depending on the spatial configuration of the hospital, entrances are in different locations and have different functions. In the three-flow model, the main entrance serves the inpatient wings as well as the outpatient departments. Outpatient departments may have separate entries, and often the maternity ward is also accessible via a separate entry, mainly to provide greater security for women and their newly born. Emergency rooms always have a separate entrance in order to keep patients from having to mix with other people, and ambulances need to reach them quickly without encountering any obstructions. Some hospitals have a helicopter platform that is directly connected to the emergency department. Staff use either the main entrance or separate entrances. Instead of differentiating entrances according to the people they serve, they can also be assigned according to the way people arrive. Special arrangements can be made for those coming by car. It is important that the arrival area be clearly recognizable and that the drop-off area can accommodate traffic without causing congestion. Finally, parking entrances should be located where they will not block traffic. The main entrances need to offer access to a public space which provides everyone with clear directions as to where they should go next.101 Often, a visit to a hospital begins at an open field, which one might expect to be designed by landscape architects and closely linked to the hospital interior. But this practice, not uncommon before the automobile Deventer Ziekenhuis, Deventer, the Netherlands, De Jong Gortemaker Algra, 2008. Entrance of the parking garage at night. The parking provides easy and fast access to the outpatient department. Academisch Ziekenhuis (now University Medical Center of Groningen – UMCG), Groningen, the Netherlands, Wytze Patijn, 1997. The hospital is characterized by its abundant public spaces. The main entrance, a spacious hall, gives access to two covered streets with a rich palette of amenities: a supermarket, bookstores, restaurants.

Meander Medisch Centrum, Amersfoort, the Netherlands, Atelier Pro, 2013. The reception area in the spacious hall has been endowed with soothing colors and rounded shapes. 59

became ubiquitous, has practically disappeared; more often than not one finds parking lots and access roads and, superimposed on them, walkways for pedestrians who have to make their way from the parking areas to the building. Visitors ‘(…) must locate the entrance drive, park their car in a parking area and find their way to the healthcare facility. Each step requires “reading” the environment, locating appropriate turning points, and finding the correct buildings. If useful environmental cues and orientation aids (such as signs and maps) are not available, there is a good chance they will become lost.’102 Since the 1990s, attempts have been made to introduce transitional zones between the hospital and the city, one strategy being to provide shops in a setting that emulates either shopping malls or urban shopping streets. In the Netherlands these zones are often referred to as ‘health boulevards’, since most of the facilities one finds there are related to health. These transitional zones might also be attractive to other forms of retail business, since the hospital guarantees a constant flow of visitors and, therefore, potential clients. Renting out retail spaces in a shopping zone can be a source of additional revenue for hospitals, but the feasibility of this approach depends on planning regulations, urban zoning and legislation pertaining to retail shopping. Certain cultural issues may also be relevant here – the atmosphere characteristic of shopping spaces might be considered not suitable for hospitals.

Los Arcos del Mar Menor University Hospital, Murcia, Spain, Casa Solo Arquitectos, 2011. The entrance is situated at the square with shades that protect visitors against the sun; a bright white wing marks the direction from the square to the entrance hall. 60

PUBLIC SPACES

GIUSEPPE LACANNA, COR WAGENAAR

Public Spaces in and Around the Hospital: Streets, Squares, Patios, Waiting Areas, Healing Gardens The way a hospital presents itself to patients and visitors is largely determined by its public spaces: the entrances, halls and interior streets, patios and all the amenities that can be found there, ranging from a simple flower shop to restaurants and supermarkets. These define an intermediate zone between the steps of the care pathway located outside the hospital and the hospital itself. It can either emphasize the latter’s function as just another step in the care pathway, albeit one requiring special technology and medical expertise, or present it as a medical machine answerable only to its own laws. There is widespread consensus on the public nature of hospitals: ‘Hospitals have always been public institutions with a special significance for the community, comparable to town halls, railway stations, theaters and museums. They shape public space.’103 Large hospitals are likely to present themselves as small cities, with parks, sports facilities and restaurants; ideally, they will be self-sufficient, even producing their own energy.104 The role of their public spaces may go beyond that of just facilitating the flows of traffic; they can be ‘just as vital to the mission of the facility as private patients or clinical spaces’.105 Public spaces can be found in all medical facilities and in very large complexes they can develop into the backbone of the entire hospital. In university medical centers this may result in an interplay between areas open to everybody and restricted areas, reflecting the juxtaposition of the city’s streets and squares with the private domain of the buildings lining them. In this respect, a hospital can function as a city in its own right: a city within the city. One may even claim that designing hospitals is as much an urban challenge as an architectural one. The University Medical Center of Groningen (UMCG) is an example of a hospital that is designed as a city, with a simple pattern of spacious covered streets connecting several squares. Its glass-walled entrance hall at the southern tip of the building provides views of the public space outside the building — mainly of the street in front of it, while the hall itself is the domain of pedestrians, who either enter from the street or arrive from the parking garage underneath. At both ends of this rectangular space, two covered streets branch off to the north, embracing the lower levels of a very long hot floor. A third street connects those two main arteries near the northern tip. The linear structure of the internal streets, which separate the clinical zones, incorporates a wide spectrum of public functions ranging from restaurants to coffee bars and from lounges to internet stations and a small, open theater for children, as well as exhibition spaces. The variety of the shops and their concentration along specific parts of the internal streets of the complex give people the impression that they are in a normal shopping street. There is even a supermarket that serves both the hospital and those with no connection to it, so that patients and people living in the neighborhood tend to mix, bridging the gap between hospital life and ‘normal’ life. The outpatient departments are located along the perimeter of the complex, while the patient

Entrance hall of the University Medical Center of Groningen (UMCG), the Netherlands, Wytze Patijn, 1997. Although designed two decades ago, the abundance of public spaces at the UMCG is still an outstanding and inspiring feature. 61

Patio at the University Medical Center of Groningen (UMCG), the Netherlands, Wytze Patijn, 1997. The roofs can be opened if the weather allows it. The representative office of the hospital board has been transferred from the historical building and integrated in the new one.

St. Olav’s Hospital, Trondheim, Norway, Nordic – Office of Architecture; Ratio Arkitekter, 2010. Color accents enliven the waiting area in the neuro center. 62

PUBLIC SPACES

wards are housed in separate pavilions above them. Several designers were called upon in order to give each outpatient department its own distinct atmosphere, and the results are especially evident in the waiting rooms, which act as intermediary spaces between the public streets, the less public outpatient areas and the private spaces of the inpatient wards above. The original urban layout is the work of Kruisheer & Hallink and the final design was furnished by Wytze Patijn. Why spend so much time and effort, and ultimately money, on the public domain in a hospital? One reason is to establish a continuity with the outside world which has positive effects on the hospital users’ experience: the patients come first. The UMCG, as one of the first Dutch hospitals to be influenced by the ideas of evidence-based design, manifests these ideas most clearly in its public spaces. Another hospital based on an urban vision which reflects a patient-centered perspective is St. Olav’s Hospital in Trondheim, Norway. With its 223,000 m2 it is a sizable facility that serves about 630,000 inhabitants; it is also a teaching institution with around 1,250 students. The proximity of a historic city center and of Norway’s most important Technical University partly determined the masterplan. The team of Frisk Architects aimed at creating an easy-to-manage, unintimidating complex of several smaller clinics which would blend in well with its urban surroundings. Probably the main difference from the Groningen complex is that these clinics have been conceived as small, independent hospitals, each hosting a variety of medical services and interdisciplinary functions. In principle, everything needed for specific clusters of diseases is available in these pavilions, minimizing the need to move patients from one part of the hospital to another. Each clinic is based on the same generic model and all are adapted to other buildings in the vicinity in order to better integrate them into their surroundings. One distinctive characteristic of St. Olav’s is that public space at the ground floor level is left open: tunnels and bridges connect the buildings. This reflects the public nature of the open spaces in older urban centers and underlines the more private nature of the clinics. As is the case in historic cities, the public domain displays a distinct hierarchy. In addition to semi-private gardens there are public streets and parks which extend between the buildings, thereby linking them with the surrounding scenery. Altogether, this is a major achievement in terms of inclusiveness, integration and differentiation. The layout of St. Olav’s outdoor spaces is based on a combination of experience, scientific research and user needs. It draws as well on the idea of the outdoors as a promoter of health and well-being. Four zones need to be considered when planning an outdoor space for healthcare settings: the parts of the building in contact with the exterior, the transition zone, the immediate surroundings and the wider neighborhood. The first zone is where contact with nature is established from inside the building, for instance via windows. The second consist of the transitional areas which mark the boundaries between the clinical world and the world outside: balconies, patios, porches, winter gardens and entrance halls. The third zone is best represented by small, inviting gardens. The fourth is the surrounding landscape. In 1999, Roger Ulrich formulated the ‘supportive garden theory’, describing four main ways of reducing patient stress. These consist in granting them a sense of control and a measure of privacy, social support, physical movement and exercise and access to nature and positive distractions. All these considerations seem to have been taken into account by the Helse-Midt Norge — the Norwegian healthcare authority — and the planners of the St. Olav’s hospital. The alternation of trees, plants and bushes, typical of the natural surroundings of the city of Trondheim, for instance, contributes to making the transition between zones gentler, sometimes almost imperceptible. From one side of the hospital, it is possible to enjoy the beauty of the nature preserve, where it is common to see people fishing for salmon and trout in the clear waters of the Nidelven River surrounded by unspoiled nature. From the other side, one has a view toward the historic city center and its old wooden houses.

St. Olav’s Hospital, reception desk in neuro center main lobby Circle Bath, Bath, UK, Foster + Partners, 2009. Public spaces inspired by the lobby of a luxury hotel

Healthcare Center for Cancer Patients, Nord Architects, Copenhagen, Denmark, 2009. The warm wood on the patios inside the building provide comfort and contrast with the building’s stark exterior that looks as if it wants to fend off intruders, creating a safe haven for those inside. Meander Medisch Centrum, Amersfoort, the Netherlands, Atelier Pro, 2013. Divided in cubicle-like units, the spacious hall (with a view on nature) can accommodate large numbers of people without giving a crowded impression. Vlietland Ziekenhuis, Schiedam, the Netherlands, EGM Architects, 2008. The generous lobby and reception space with its wooden ceiling creates a welcoming atmosphere for patients and visitors.

PUBLIC SPACES IN AND AROUND THE HOSPITAL

63

Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, USA, Frank Gehry, 2010. Spectacularly designed, the building’s interior space contributes to the building’s quality as an architectural landmark. Rey Juan Carlos Hospital, Madrid, Spain, Rafael de La-Hoz, 2012. The design combines futuristic architectural features with the homely, warm atmosphere that is enhanced by the design of the interior gardens. New Hospital Hvidovre Extension, Hvidovre, Denmark, Schmidt Hammer Lassen Architects with Aarhus Arkitekterne, winning proposal, 2013. Rendering of the interior covered patio with warm, wooden flooring, comfortable lounges and greenery Academic Medical Center (AMC), Amsterdam, the Netherlands, Architectengroep Duintjer in cooperation with Dick van Mourik, 1981–1985. The daylit internal street creates a large public space.

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PUBLIC SPACES

NOOR MENS

Wayfinding: Signage and Orientation Systems

The visual form of Los Angeles, illustration from Kevin Lynch, The Image of the City, first published in 1960. The book explains basic parameters of wayfinding.

Victoria and Vani Vilas General Hospital, Bangalore, India, 1935. Pictograms and signage system

One trait hospitals have in common with cities is the impossibility for anyone visiting them to determine at one glance how to reach his or her destination. Often, different routes branch off from the main hospital entrance. All the corridors look exactly the same, and the signs bearing the complex names of a multitude of medical departments often make the search even more complicated. Patients wandering through these hospital spaces can experience increased stress and irritation. In fact, research inspired by the ideas of evidencebased design has shown that this problem of wayfinding can become quite costly; for when patients and visitors are obliged to ask the staff for directions, the latter are diverted from the tasks they are hired to perform. Craig Zimring discovered that the staff of a 300-bed hospital in Atlanta spent 4,500 hours per year dealing with such questions, which resulted in a loss of US $ 220,000.106 The basis for easy wayfinding is a proper logistical organization of the building. A clear zoning plan and layout are essential for enabling people to understand where they are and how they can reach their destination. Other measures — design-based distinctions that give various departments a clearly recognizable identity, signage systems, digital apps — may be very helpful in this regard, but they can never compensate for a chaotic, incomprehensible overall layout. How do people identify places? The theoretical groundwork needed to answer this question was presented in 1960 by Kevin Lynch in his seminal book The Image of the City. Although he wrote mainly about cities, his findings are also applicable to large and diverse buildings such as hospitals. The initial requirement for successfully finding one’s way is a fixed point of reference. Wherever people are, they should be aware of the spatial relations of the surroundings with this one point. The key to grasping how wayfinding works is a process that Lynch termed ‘mental mapping’. Mental maps contain five elements: (1) paths — the routes people follow when moving through cities; (2) edges — borders and discontinuities; (3) districts — areas with a specific character that sets them apart from other areas; (4) nodes — places that offer a range of possible routes and demand special attention; and, finally (5) landmarks — easily recognizable buildings or objects. Hospitals that contain stable, distinctive and highly recognizable paths, nodes, landmarks, edges and districts are inherently more legible and 65

Akademicki Szpital Kliniczny, Wroclaw, Poland. Designer Jarek Kowalczyk, Studio Fuerte, conceived a combination of consistent signage systems, nameplates, a colored floorplan and pictograms.

Emma Kinderziekenhuis, Amsterdam, the Netherlands, refurbishment by OD205, 2015. Colorful pictograms on the floor lead the way.

66

PUBLIC SPACES

easier to navigate than those that do not. It is difficult to mentally tag specific places in one’s mental map in hospitals which lack a discernable character or scalar hierarchy of these elements.107 Recognition and identification of specific places in buildings can be enhanced by setting them clearly apart from other places through the use of colors, materials and furnishings. A general layout that is easy to understand — and enhanced features that facilitate people’s capacity for making mental maps — should be supported by a clear and consistent signage system. Creating such systems has long been recognized as a crucial aspect in any large complex. In hospitals, graphic signs are used to inform patients and visitors. Apart from the ground floor, floors in a hospital are hardly ever continuous: in order to get from one place to another on the fourth floor, for instance, one often first has to go back to the ground floor. Naturally, this makes it more difficult to devise effective signage systems, and sometimes it is considered better to refer to buildings instead of traffic arteries (i.e. ‘districts’ instead of ‘paths’ in terms of Lynch’s mental maps). After establishing the principles of the signage system — in other words, to what it should direct patients and visitors — one must decide on the actual layout of the signs. The most important thing is to ensure that the chosen solution is applied throughout the hospital in a wholly consistent manner. Finally, it should be noted that touch screens can complement the designers’ toolkit, providing interactive support to help guide people to their destinations. Maps are another obvious tool for facilitating wayfinding. They can be provided at the entrance and also be incorporated into a hospital’s interior decoration. But their effectiveness should not be overrated, as some people do not know how to read them. Finally, apps for mobile phones have been developed that help their users navigate through buildings in much the same way as they facilitate wayfinding in cities. They have revolutionized the latter process, but to tackle the problems of navigation in complex, multistory buildings they have to be custom-made. Moreover, they are obviously not helpful in places where the use of mobile phones is prohibited.

TOM GUTHKNECHT

Planning: an Integral Approach Hospital design should be guided by a new, integral approach, and this publication selects subjects and built examples which are particularly suitable for formulating this new approach to the planning of modern healthcare facilities. It attempts to demonstrate how the various elements of this approach can be assembled in different compositions and how, in each project, context and specific circumstances should be analyzed. It must be stated that there is no such thing as the ‘right’ hospital. A health facility is rather an assembly of contradictions and conflicting interests of various parties and stakeholders, which may result in different outcomes in each case. Health facility planning can best be described, therefore, as a ‘landscape of compromises’ situated on ceaselessly shifting ground. Health facility planning is in crisis today, and the reasons for this are not hard to discover: • Imagine a business which neglects serious research for decades. • Imagine a public health effort which costs billions of euros per year in Western countries but lacks accountability with respect to efficiency and efficacy. • Finally, imagine a crucial area of public interest which does not receive the political and economic support which would allow it to safeguard existing know-how, let alone develop it further. These deficiencies characterize the state of health facility planning today. Centralized planning departments, which previously ensured a certain level of standardization for health facility projects, have been closed in many countries. Currently, individual hospitals are empowered to finance and build projects on their own. The downside of this change is that hospital planning expertise, once safeguarded by the central planning departments, is becoming increasingly fragmented and even ebbing away. It is high time that governments acknowledge the urgent need, first, to allocate significant resources to the creation of independent entities with expert knowledge in the management of health facility planning and, second, to further develop medical, operational, ethical and financial standards aimed at improving the performance of these facilities, while keeping the essential goal in mind: the well-being of the patient. One of the many problems in current health facility planning is the lack of understanding of a project’s context at its inception. In many cases, the conditions and context of the project are unsatisfactory right from the beginning. Here are some commonly found examples: • Insufficient clarity regarding the need for the project and the likely effect of its introduction into the existing context. • Insufficient resources or resources managed on behalf of the healthcare provider but without sufficient expertise. • Inability of the stakeholders involved in the planning process to speak the same language (typically, medical staff who are unable to read and understand architectural drawings, and architects and engineers who lack the necessary vocabulary and knowledge of medical processes). • Insufficient or inaccessible planning standards; or, in some cases, obsolete planning standards which have not been updated due to a lack of funds. • Absence of a satisfactory strategic design for a project at its inception. • Failure to develop, from the start, an ‘operational sketch design’ — i.e., broad operational guidelines at a similar level of detail as the architectural sketch design. At a later stage, this results in the absence of a much more detailed operational concept which should correspond to the architectural detailed design and which is necessary for the latter’s validation. These problems can hamper a project at the beginning and continue to do so at later stages. When left unaddressed until a later time, strategic issues cause enormous problems and have significant cost consequences. It is therefore necessary to clearly define the feasibility of the health facility project in detail prior to starting the actual design process. 67

The Patient’s Perspective The likelihood that the patient’s perspective will prevail in today’s health facility building process is essentially a matter of pure chance. It is important to separate specific, individual design choices and decisions from the qualities of a building that, from a patient’s perspective, all health facilities should have. The problem, however, is that there is no standard ‘patient’s perspective’, just as there is no standard hospital. Contextual, cultural, regulatory, functional and economic differences all contribute to different patient perspectives. The perspective of an individual patient can also vary vastly in different contexts. For example: a woman arriving as a parent at the emergency room with her six-year-old child with a non-life-threatening but heavily bleeding head laceration from a bicycle fall could be in a highly emotional state, but different from the emotional state she is in as a 46-yearold patient waiting to get her second chemotherapy treatment in the oncology department. Successful health facility design must therefore provide a wide scope of design solutions which cater to patient needs in an appropriate and dignified manner over a wide range of situations. Functional Perspective Health facility planning cannot be explained in a linear way. The building of a ‘spatial container’ for the dynamically changing medical services provided within it is bound to generate constant contradictions in its attempt to reconcile conflicting demands. Simplistic approaches to health facility planning are, therefore, certain to fail. Another mistake committed very often is confusing complicated systems with complex systems. While complicated systems, such as high-tech devices with a large number of highly differentiated parts, can be structured and managed by simplification and prioritization, simplification as an approach is dangerous and misleading in the context of complexity. Whereas complicated situations are characterized by a multitude of interacting but predictable components and parameters, a complex planning situation can sometimes arise due to unpredictable behavior of, and interaction between, just a few parameters. Functional planning of complicated situations can therefore be based on clearly defined variants, while complex functional planning, such as departmental interactions in hospitals, should be based on scenarios and their operational probability. By maintaining a clear distinction between complicated and complex planning situations, the entire process of planning health facilities becomes more transparent and easier to handle. It is, however, necessary to devote sufficient resources for planning the interface between medical and ancillary processes, workflows, team activities and departments. Functional planning confronts a major challenge in the task of translating a complex and iterative planning and design process into a linear and sequential building design and realization process. Challenges for Future Design Current health facility design needs to be challenged, since it often provides buildings for services that many societies can no longer afford. In recent years, process optimization came to be seen as an important remedy for rising healthcare costs, but it is now obvious that process optimization alone is not sufficient. Today, process and workflow design is totally separated from health facility design, with serious negative effects. In the future, two features should become an integral part of health facility design. First, building design must contribute to improving the operational and financial performance of the healthcare provider and each design variant must be assessed as to the extent it contributes to operational effectiveness. Second, the quality and performance levels of the medical services, and patient/staff environment issues must be taken into account at the same level of detail and in parallel with the assessment of building efficiency, in order to avoid design decisions which may be aimed at improving efficiency but which actually lead to lower quality instead. Health facility design is thus faced with the challenge of contributing simultaneously to quality improvement, operational effectiveness and cost reduction. 68

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TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Outpatient Department

Martin Luther King, Jr. Outpatient Center, Los Angeles, HMC Architects, 2014. Reception and generic consultation rooms Orbis Medisch Centrum, Sittard, the Netherlands, Bonnema Architecten, 2011. This centralized waiting area serves several outpatient units, allowing a more generous space. An adjacent atrium provides daylighting.

Few components of the hospital have increased in size and importance as fast as the outpatient departments. In some countries, however, notably Germany, the services they provide are also offered outside hospitals, resulting in costly redundancies. Formerly limited to low-risk medical services, outpatient departments offer an ever-increasing array of interventions, including those that formerly required patients to remain in the hospital for several days. In 1980, American hospitals earned only 12Æ% of their revenue from medical services provided in outpatient departments; in the 1990s it had already increased to more than 50Æ%.108 What distinguishes the outpatient department from the rest of the hospital is that even though patients return home after treatment, this part of the hospital has become the busiest (and therefore the most traffic-intensive), in part because patients rarely come alone. Friends or family accompany them and sometimes wait until the medical procedures are completed. The latter vary from interviews in consultation rooms to surgery, from simple diagnostic procedures to complex but (usually) low-risk interventions. Some procedures may take only a few minutes while others can last all day. Spaces Outpatient departments today contain extensive waiting areas, consultation and examination rooms, various types of treatment spaces and all the technology, supplies, logistics and other facilities required to run them. These can be designed as generic units suitable for various disciplines (general surgery, orthopedics, plastic surgery, internal medicine, rheumatology, etc.) specifically designed for individual disciplines (ENT, ophthalmology, urology, etc.), or thematically organized (mother and child center, oncological center, etc.). The thematic outpatient facilities are sometimes located near the corresponding hot floor functions. If inpatient wards are also needed for specific themes and situated close to the corresponding outpatient and hot floor functions, this may result in a layout reminiscent of the last generation of pavilion hospitals, which also developed as separate, self-contained units corresponding to specific medical departments. Large hospitals are sometimes organized in this way, which presupposes a robust and logical logistic structure enabling outpatients and visitors to find their way with ease through the entire hospital complex. Often, however, outpatient departments are organized and clustered together in units, usually running on an 8.00 am–5.00 pm schedule, separated from the other, 24/7 facilities of the hospital.

69

Academic Medical Center (AMC), Amsterdam, the Netherlands, Architectengroep Duintjer in cooperation with Dick van Mourik, 1981–1985. The photo shows the refurbishment of the waiting area in the AMC daycare center by Valtos Architecten. There is no longer a clear distinction between the waiting area and the reception desk.

Spaarne Ziekenhuis, Hoofddorp, the Netherlands, Wiegerinck Architecten, 2013. This daylit waiting area emulates a hotel lobby.

Perspective of the Patient Typical outpatients come to the hospital from home. General practitioners and other healthcare providers working outside the hospital normally supervise the part of the care pathway preceding the first outpatient visit, and they take over once the (multiple) trips to the hospital are finished. After having reported at the reception desk, the patient takes a seat in a designated waiting area. Waiting is often by far the most time-consuming ‘activity’ in this department. The overall layout of the hospital determines where the outpatient departments are located, whether or not they have a separate entrance and whether they are grouped together as a separate, self-contained cluster, as a specific zone in the hospital with dedicated outpatient units or as decentralized units spread throughout the hospital building. Very often, outpatient departments relate more closely to parts of the care pathway accommodated outside the hospital than to the parts within the hospital, which makes it feasible to build them as satellite clinics, integrated with other healthcare services in relatively small community health centers. The Examination Table The examination table is the heart of the outpatient department. It can be a generic or a very specific piece of equipment, depending on the requirements of the medical specialty involved. For example, the pediatrics department requires a consultation table designed for infants and toddlers, with reduced surface and increased height. Other departments, such as gynecology, require specialized examination tables, including leg support and adjustable back position. The placement of the examination table should be such that the medical staff is able to thoroughly examine the patient; it can be placed in a corner with two sides adjacent to the wall, with one side adjacent to the wall or free-standing, allowing for movement around the patient. The Consultation and Examination Areas The consultation and examination areas can function jointly in a combined specialty-specific or generic consultation room with or without internal partitions, or separately, with the consultation and examination rooms connected to each other by a door or by a (restricted) corridor. Each variant corresponds to a model of traffic flow — either separating or integrating medical staff routes with patient routes. In the consultation area, the medical staff have access to patient information and a working desk, where a great part of the conversation with the patient takes place. Equipment such as the examination table, instruments and disposables are needed in the examination area. A hand-washing facility in the examination area is mandatory. Mobile or fixed diagnosis and treatment equipment might need to be accommodated in the examination area for specific patient groups, for which exact specifications need to be made. The more generic the design of the consultation room, the more functions it can support. Windows should not compromise the patient’s privacy. The Unit The unit comprises all the consultation and examination areas, along with the reception area, waiting areas and, potentially, the associated diagnostic and back-office facilities. The medical processes can be organized in a monofunctional manner, with segmented frontoffice functions per specialist, or in a multifunctional manner, allowing for interdisciplinary consultation and flexible use of front-office facilities. Digitized access to the patient’s complete health record must be provided.

THE DEPARTMENT An outpatient department can be set up in various ways. One option is the so-called ‘one stop shop’ model, where all the procedures take place in the same area of the hospital. In other cases, patients need to visit various places in the building — the outpatient unit itself, 70

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the radiology department for a CT scan and the laboratory for blood tests, for instance. Small hospitals, lacking advanced equipment, sometimes have to refer patients to better equipped facilities for specific diagnostic tests. Here we will discuss four models for organizing the outpatient department, each featuring a different combination of the determining factors: availability of digital or paperbased information systems, location of the studies, administration and management offices, layout of waiting rooms, the level of specificity of the consultation and examination areas, the shape of the building and daylight accessibility. Model 1: Monofunctional outpatient department The first model (A) uses the consultation and examination areas as a traditional ‘doctor’s office’. The level of digitization is usually low. The medical staff uses the consultation and examination rooms not only to consult with patients but also to study, do administrative work and conduct meetings. One of the advantages of this model is direct access to daylight A

Exam. room

Doctor´ s office

Exam. room

B ack office A rchive

B

Evolution of the outpatient department A Monofunctional outpatient department The consultation and examination room doubles as a medical specialist’s study, making it and the adjacent examination area(s) unusable by other disciplines outside the specialist’s consultation hours. B Separate medical specialist’s study The separation of the examination area from the medical specialist’s study allows for a more effective use of the consultation and examination rooms. C Complete separation of front-office and back-office areas The archive and back-office functions are situated outside the front-office area (consultation rooms, reception, waiting areas); the use of flexible, shared workspaces for medical specialists and assistants allows for better utilization and collaboration of both the front- and backoffice facilities. D Multifunctional outpatient department With the advent of electronic patient records and centralized, digital appointment scheduling systems, the hospital no longer needs a paper-based patient record archive; interdisciplinary collaboration and workspace flexibility are facilitated by this model.

Exam. room

Doctor´ s office

Exam. room

B ack office A rchive

Exam. room

Doctor´ s office

Exam. room

B ack office A rchive

Dedicated reception desk

Dedicated reception desk

Dedicated reception desk

Decentraliz ed waiting area

Decentraliz ed waiting area

Decentraliz ed waiting area

Doctor' s study

Doctor' s study

Doctor' s study

Exam. Consultation Exam. room room room

Exam. Consultation Exam. room room room

Exam. Consultation Exam. room room room

B ack office A rchive

B ack office A rchive

B ack office A rchive

Dedicated reception desk

Dedicated reception desk

Dedicated reception desk

Decentraliz ed waiting area

Decentraliz ed waiting area

Decentraliz ed waiting area

B ack office A rchive

B ack office A rchive

B ack office A rchive

Study, administration and management offices

Study, administration and management offices

Study, administration and management offices

Consultation Consultation Consultation and and and examination examination examination room room room

Consultation Consultation Consultation and and and examination examination examination room room room

Consultation Consultation Consultation and and and examination examination examination room room room

C

Dedicated reception desk

Dedicated reception desk

Dedicated reception desk

Decentraliz ed waiting area

Decentraliz ed waiting area

Decentraliz ed waiting area

D

Digitiz ed access to patient records

Flexible study and management area

Consultation Consultation Consultation and and and examination examination examination room room room

Consultation Consultation Consultation and and and examination examination examination room room room

Consultation Consultation Consultation and and and examination examination examination room room room

Multifunctional reception desk

Centraliz ed waiting area

OUTPATIENT DEPARTMENT

71

Multifuncti

Flexible and centraliz ed wai area

Flexible study and management area

Flexible study and management area

Study and management A rea

Legend

Waiting area

Patient Departm Patient department tr

Consultation A Examination area

Study and management area rea

Patient Department T raffic Patient department traffic

Consultation area

Medical staff traffic

B ack office area

General traffic

General

traffic Front office area

Study and management area

Departmental traffic

Legenda Consultation A Examination area

rea

Patient Department T raffic Patient department traffic

Consultation area

Medical staff traffic

B ack office area

General traffic

Public area

Waiting area

Outpatient department

Front office area

Consultation and examination room

Study and management area

Patient's process steps

Treatment process steps

Logistical process steps

Information flows

Describes symptoms Consults and undergoes examination Discusses diagnosis, treatment options and follow-up procedures Books the next appointment

Analyses medical history and symptom Consults and performs examination Discusses diagnosis, treatment options and follow-up procedures Schedules the next appointment

Replenishes (at consultation room level) - Sterile instr. and disposables - Clean linen and other materials Provides cleaning services Collects waste and used materials

Medical record management Information verification (patient information, diagnostic results, medical history, etc.) Multidisciplinary collaboration and information sharing

Reception area

Departmental logistics

Registers (and sometimes explains medical condition and nature of appointment) Books the next appointment

Verifies and updates information in the patient's medical record (Sometimes discusses medical condition and follow-up appointments) Schedules the (next) appointment(s)

Replenishes (at outpatient department level) - Sterile instr. and disposables - Medication - Clean linen and other materials Provides maintenance and replacement services for equipment and facilities Provides cleaning services Collects waste and used materials

Patient registration Patient record verification and update Patient referrals and appointment scheduling

Waiting area

Departmental logistics

Waits for consultation and to book follow-up appointments Uses hospitality services

Calls in or accompanies patient to the consultation room

Replenishes informational folders, beverages, etc. (at waiting area level) Provides maintenance and replacement services for furniture and televisions/monitors Provides cleaning services Collects waste

Informational folders Information on waiting times, announcements, etc. on display monitors/televisions

Hospital-level logistics Patient arrives for appointment

Patient leaves after appointment

Hot floor

Storage and logistics, pharmacy and medication rooms Patient wards and day treatment

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TREATMENT AREAS

Medical staff traffic De

General and traffic Flexible study management area

Front office area

Legenda

Waiting area

rea

Consultation area Departmental traffic B ack office area

Study and management A rea

Legend

Legenda Consultation A Examination area

Flexible study and management area

Study and management A rea

Legend

Flexible and centraliz ed waiting area

Multifunctional reception desk Departmental traffic

Departmental traffic

General traffic

Multifunctional reception desk

General traffic

Departmental traffic

Multifunctional reception desk

Flexible and centraliz ed waiting area

General traffic

General traffic

Multifunctional reception desk

Departmental traffic

General traffic

Multifunctional reception desk

Flexible and centraliz ed waiting area

General traffic

De

Multifunctional reception desk

Multifunctional reception desk

Departmental traffic

Example of a multifunctional outpatient department: configuration and traffic flows

from the consultation and examination rooms. While the layout is compact and seems efficient from the perspective of the medical staff, it may lead to inefficient and cumbersome process flows from the perspective of the patient and also from the perspective of the outpatient department as a whole. Waiting areas need to be close to the consultation rooms, positioned along the corridor, and therefore, more often than not, are deprived of natural light or, at times, located in special niches with direct daylight. Some outpatient units might have receptionists, usually stationed at counters in the waiting area to respond to patients’ queries and assist in tasks such as completing administrative forms. This activity within earshot of other patients can cause lack of privacy issues. The same corridor where the waiting area is situated might also be part of the route to other medical specialties, leading to difficult patient traffic flows. Model 2: Separate medical specialist’s study The second model (B) groups the doctors’ studies, administration and management offices and meeting rooms in a separate area of the hospital, allowing the outpatient unit to be used exclusively for patient consultations. This model usually consists of a corridor with consultation and examination rooms on the sides and several decentralized waiting areas, with archives and back-office facilities between them. The reception desk is situated in proximity of the consultation rooms it serves, so that the process of making a follow-up appointment is still a rather public matter. All traffic flows could potentially end up leading through the same space, be it patients waiting for an appointment, patients going to a department situated at the end of the corridor or medical and support staff moving from one department to another. This combination of traffic routes can lead to disorientation and slowed-down processes. On the other hand, this model allows for direct natural light in all patient areas, with the exception of the corridor. Model 3: Complete separation of front-office and back-office areas The third model (C) situates the archive and back-office facilities near the doctors’ studies, administration and management offices and meeting rooms, instead of in the reception area. As a result, all activities not requiring the patient’s presence take place in a separate area to which they have no access, thereby strictly separating back-office medical staff traffic from patient traffic. Restricted corridors might improve the access of medical staff members to each other and to the administration and management area, allowing for better collaboration and eliminating the need for staff to walk through the waiting rooms and public corridors. This model usually consists of a double-loaded corridor, with consultation and examination rooms of various medical specialties positioned on the sides. However, each medical specialty has an individual reception desk and waiting area, separated by the main traffic corridor. Traffic routes of patients and medical staff are separated. This allows for fast access to various back-office areas. Direct natural light is available in the consultation room; however, the corridors and the examination rooms receive little or only indirect natural light, due to their flanked position.

Process flows in the outpatient department are clustered in three functional areas: the consultation and examination room, the reception area and the waiting area. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.

Model 4: Multifunctional outpatient department The fourth model (D) is based on the use of fully digitized patient records, permitting a high degree of flexibility in the location of the waiting areas, the back-office facilities, doctors’ offices and centralized reception and waiting areas. Although these larger waiting areas could increase the risk of patient-to-patient infection, this layout, when well-designed and well-managed, could facilitate greater patient comfort and privacy, faster traffic and easier access. This model usually consists of a double-loaded central corridor and two lateral corridors for patient traffic, with examination areas connected to a restricted access corridor for the medical staff. The patient arrives at a centralized front desk and is directed to the central waiting area. Access to daylight in the corridors is achieved by the use of internal courtyards and skylights. OUTPATIENT DEPARTMENT

73

Appointm ent scheduling

Monofunctional/ specialist- centered outpatient department - Paper- based medical records - Decentraliz ed waiting areas - Dedicated consultation room/ unit per medical specialist

- Electronic medical records - Centraliz ed waiting areas - Shared consultation rooms/ units

Appointm ent scheduling 1 T he patient or GP calls the hospital to schedule an appointment.

Appointm ent scheduling 1 T he patient or GP calls the hospital to schedule an appointment or schedule it online. 2 A medical assistant work ing in the back - office area tak es the patient' s call, verifies and updates information in the patient' s electronic medical record and schedules the appointment and, if necessary, additional appointments ( blood tests, radiological scans, etc.) in the right seq uence. 3 T he patient' s electronic medical record is accessible anytime, anywhere. Step eliminated

2 A medical assistant work ing at the departmental reception tak es the patient' s call and schedules the appointment ( no separation of frontand back - office processes) . 3 T he patient' s medical record is transported to the specific outpatient department prior to the appointment Arriv al and registration 4 T he patient arrives at the hospital' s central reception and is directed to the departmental reception.

Consultation

5 T he patient arrives and registers at the departmental reception, sometimes explaining the medical condition and nature of the appointment within earshot of other waiting patients.

Arriv al and registration 4 T he patient arrives and registers at the hospital' s central reception and receives information on the appointment( s) and the expected waiting time in case of delays. 5 T he patient is automatically registered at all relevant departments, undergoes pre- scheduled diagnostic tests and arrives at the departmental reception for the primary appointment at the scheduled time.

6 A medical assistant at the departmental reception retrieves the patient' s paper- based medical record, verifies and updates information within earshot of other patients, check s if diagnostic tests are missing ( blood tests, radiological scans, etc.) , and if so, sends the patient to the diagnostic department( s) . T he patient' s primary appointment is rescheduled ( if possible, later in the day) .

6 T he medical assistant does a final check to ensure that everything needed for the appointment is complete.

7 T he patient registers, waits and undergoes the req uired tests at the diagnostics department ( clinical chemistry, radiology, etc.) .

7 Step eliminated

8 T he patient arrives back and re- registers for the primary appointment at the departmental reception.

8 Step eliminated

Registering and w aiting 9 T he patient waits in the departmental waiting area, situated q uite often in a corridor without daylight, usually with no information on the expected waiting time. 10 T he waiting patient can potentially overhear medical specialists and assistants discussing other patients ( as this happens outside the consultation rooms, usually in the corridor or reception areas) . 11 T he medical assistant tak es the medical record to the medical specialist' s consultation room and calls the patient in.

Consultation and/or treatm ent 12 T he patient explains the medical condition ( again) and the medical specialist ask s follow- up q uestions performs tests and discusses the diagnosis and treatment plan with the patient. 13 T he medical specialist updates the paper- based medical record and the medical assistant tak es the record back to the departmental reception ( and brings in the record of the next patient) . 14 T he patient leaves the room. T he medical specialist calls in the next patient. 15 When not seeing patients, the medical specialist uses the consultation room as an office space for study and administrative task s. T he consultation room is not used by others when the specialist is away.

Post consultation

Multifunctional outpatient department

Monofunctional/specialist-centered vs. multifunctional outpatient department The multifunctional outpatient department optimizes processes from a patient-centered perspective, resulting in fewer steps in the patient process, reduced waiting times, better quality of care and lower costs.

Registering and w aiting 9 T he patient arrives at the expected appointment time at the decentral waiting area ( situated so as to have sufficent daylight) . 10 Dialog between medical specialists and assistants tak es place out of earshot of waiting patients ( usually in areas between the consultation rooms and the departmental reception) . 11 A medical assistant accompanies the patient to the consultation room, retrieves the patient' s electronic medical record and conducts tests and goes through check lists, if any, prior to the arrival of the medical specialist. Consultation and/or treatm ent 12 T he medical specialist check s the latest information in the patient' s electronic medical record, ask s follow- up q uestions, performs tests and discusses the diagnosis and treatment plan with the patient. 13 T he electronic medical record is updated by the medical specialist. 14 T he patient stays in the room with the medical assistant to schedule follow- up appointments, if req uired. T he medical specialist goes to an adj acent consultation room to see the next patient. 15 T he consultation room is used primarily for patient appointments. When one medical specialist is away, the room is used by another specialist. Desk s/ work spaces for study and administrative task s are situated in a back - office area.

Follow - up appointm ent 16 T he patient and a medical assistant schedule a follow- up appointment at the departmental reception within earshot of other patients in the waiting area. 17 When appointments at other departments are req uired, the medical assistant calls these departments individually to schedule appointments or the patient goes to each of these departments.

Follow - up appointm ent 16 T he patient and the medical assistant schedule all necessary appointments at various departments in the consultation room using the hospital' s digital appointment scheduling system 17 Step eliminated

Back- office processes 18 T he paper- based medical records at the departments are transported daily from and to the hospital archive. 19 B ack - office processes ( telephony, study and administrative task s, etc.) are not separated from front- office processes ( reception, patient appointments, etc.) .

Back- office processes 18 Step eliminated 19 B ack - office processes are separated from front- office processes.

A dditional space for accompanying persons

A dditional space for accompanying persons

Medical specialist' s work space for back - office task s ( study, administrative task s, etc.)

Consultation and examination room with typical components: the consultation area (beige) with additional room for accompanying persons and walkers/wheelchairs (green), the examination area (orange) and the doctor’s workspace (purple); the archive is a component specific to outpatient departments functioning without electronic medical records.

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TREATMENT AREAS

( Digital) archive

1 Standard examination room eq uipment 1 Examination table

2

Specific examination room eq uipment, e.g. gynecology 3

2 Gynecological examination table 3 Ultrasound machine

TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Inpatient Wards Unlike outpatients, inpatients have to stay in the hospital at least overnight, and quite often for several days. Hospitalization is always a disruptive experience, forcing new roles upon the patient from the moment he or she enters the patient room. It triggers several responses that have sometimes been summarized as regression (the patient returns to a child-like existence and surrenders control to the medical staff), frustration (because it has become impossible to engage in normal, everyday life), egocentricity (enhanced by being forced into a passive role) and, obviously, fear.109 A number of other factors contribute to the patient’s feelings of discomfort: separation from family and friends, who may visit the patient but now belong to a world the hospitalized patient is, albeit temporarily, no longer a part of; forced cohabitation with total strangers and the unpleasantness of simultaneous visits by patients’ families in multi-bed rooms that are still the norm in many countries; lack of privacy and the impossibility of creating a private realm, however limited; exposure to uncomfortable levels of noise. How can things be improved? Reducing the number of inpatients and transferring as many therapies and interventions as possible to outpatient departments undoubtedly contribute to a better patient experience. Thus, in Germany, for example, it is hoped that the number of inpatient beds will decline by at least 20Æ% in the years ahead.110 Minimizing the length of hospitalization by efficiently arranging all the steps in a care pathway is a reasonable strategy, and one that enhances the trend toward shorter stays. But what can be done to make the days and nights spent in the hospital less discomforting? Although the encounter with medical specialists and their technologies is obviously vital for hospital patients, what often has a bigger impact on the way they experience their stay is their interaction with the nursing and support staff. Since the ideals of patient-centered care gained ground in the 1970s, many initiatives have evolved for softening the cold and impersonal characteristics associated with the hospital as a medical machine. One of the best known is the ‘Planetree’ concept. Founded in San Francisco in 1978 by Angelica Thieriot, the Planetree organization emphasizes the need to take into account the patient’s subjective experiences. It asserts that direct access to the medical staff, customized information, and facilities which enable relatives and friends to offer active support are particularly important, as is the role of architecture (especially in the patient unit). Beyond noting the value of natural light and soothing colors, this approach stresses the advantages of interior decoration and furniture that resemble home. The Planetree organization even started a certification program for architectural firms.

Martini Ziekenhuis, Groningen, the Netherlands, Burger Grunstra Architecten, 2007. Two-patient bedroom

Trends Undoubtedly the most important trend in the last two decades has been the increasing acceptance of the single-bed room as the new standard for hospitals — although in practice multi-bed rooms are still found everywhere (in 2011 in Germany the percentage of single-bed rooms in hospitals was approximately 15Æ%).111 Single-bed rooms can go a long way toward addressing many of the issues raised by multi-bed rooms, such as lack of privacy, risk of hospital-acquired infections and the experience of sharing a room with strangers, and they are especially welcomed by patients when they are spacious enough to allow family to stay overnight occasionally. Evidence-based design research supports the positive impact of single-bed rooms which also reduce the risk of medication errors (the latter is no minor problem: in Germany, the number of people dying as a consequence of accidentally receiving the wrong medication exceeds the death toll of traffic accidents).112 Even though they occupy a lot of space and can increase the distance between the patients and nurses if the standard use of a central nursing station per ward stays unchanged (decentralized nursing solves this issue), investment in single-bed rooms is seen as profitable, since they could have a positive impact on health outcomes, increase patient satisfaction and reduce litigation. Also, patients may speak to the doctor more freely if there are no other people in the room.113

75

Building spacious single-bed rooms facilitates another development: the concentration of as many medical processes in the patient room as technically and spatially feasible. The more mobile medical equipment and devices become — computers on wheels (‘COWS’) or handhelds (including some types of imaging and diagnostic machines) — the less need there is to transport patients through the building, a time-consuming and stressful activity that increases the risk of infection. A special case are the luxurious premium suites addressing a wealthy clientele.114 The Robert Koch Krankenhaus in Stuttgart, for instance, offers VIP suites of 63, 58 and 41 m2 on the top floor.115 Compared to the dynamic changes in the high-tech hot floor departments in hospitals, the design of inpatient wards has been relatively stable. Ward design today still closely reflects concepts developed 30 years ago, when it was based on the per-bed per-night compensation model, which gave hospitals little incentive to reduce the length of stay. Recent developments are just beginning to have a significant influence on ward design: • The increasing implementation of flat-fee compensation for services (per diagnosis-related group [DRG] or outcome-based) provides incentives for length-of-stay reduction. • Aging populations translate into ever-increasing numbers of older, multi morbid patients. Such patients need care not only for the specific medical procedure they are admitted for, but also for their other medical conditions. This could result in a shift from specialty-specific wards (cardiology, orthopedics) to multidisciplinary wards. • Patient wards providing acute services for elderly patients (surgery, neurology, cardiology, internal medicine, etc.) increasingly need to deal with patients with dementia and gerontopsychiatric conditions, requiring modifications in the built environment. • Early and intensive reactivation and rehabilitation after medical interventions lead to better medical outcomes and reduced lengths of stay. These inpatient rehabilitation services need to be accommodated by ward design. • The nursing staff in inpatient wards spend more than a third of their time walking or searching for people or things, and the layout of the wards is one of the biggest reasons for this inefficiency. Injury and fatigue prevention should be achieved by an efficient, compact and intuitive layout, incorporating ‘human factors’ engineering to improve safety.

Proposal for a single-patient room, Perkins + Will, 2011. The room has a family zone allowing for accommodation of family members. Deventer Ziekenhuis, Deventer, the Netherlands, De Jong Gortemaker Algra, 2008. Multi-bedroom unit with low window sill to enable a view of the outside

76

TREATMENT AREAS

Patient rooms are usually equipped with monitoring equipment, oxygen, compressed air and suction — sufficient for relatively simple medical procedures carried out in the room. The increasing number of interventions performed in patient rooms and the trend toward dynamically scaling up and scaling down care levels in the room — instead of transferring the patient to another ward — are likely to result in additional equipment (which is stowed away when not in use). All patient rooms have a patient bed, mostly electrically powered to enable patients to adjust their position and to support ergonomic nursing at the bedside. Equally important for ergonomic nursing are mobile or ceiling-mounted patient lifts.

Many hospitals offer a personalized digital health, entertainment and services environment, with flat screens that serve as a television set but also allow patients to order meals, surf the Internet and, ideally, take a look at their health stats.

Design for the Centre hospitalier de l’Université de Montréal (CHUM), Montreal, Canada, Neuf architect(e)s, CannonDesign, 2018. Rendering of a single-patient bedroom with a family zone

Spaces Inpatient wards are subdivided into nursing units of various sizes. Unit size depends on factors such as the severity of the medical condition of the average patient, the nursing concept and the number of beds supervised by each nurse, usually four to eight beds, quite often leading to a total of between 30 and 40 beds per nursing unit. In some countries the size of the nursing unit is considerably larger than that. One of the fundamental issues in nursing in the inpatient wards is the location of the nursing station. Whereas central nursing stations were long the norm, advances in information technology have made decentralized, mobile workstations a safe, efficient and patient-friendly alternative; indeed, research appears to show that ‘(…) significantly more time was spent on phone, computer and paper administration in each of the centralized units compared to decentralized units.’116 Some concepts regarding reorganization of ward design in Switzerland have even abandoned the central nursing station as a spatial function altogether — a trend that can be seen in studies showing that nursing interaction with the patient in the central nursing station model is constantly in decline. Hybrid nursing stations combine bedside nursing and administration with (de)centralized workstations. Whether the hybrid model leads to an increase in the much-needed contact between nursing staff and patients remains to be seen. A typical ward also comprises facilities such as consultation and examination rooms, spaces for patients to interact with visitors and a small coffee corner for patients who are able to walk but find such facilities in the public areas to be too far away. Four zones can be distinguished in the patient room: the immediate environment of the patient; surrounding that, the area used by the caregiver; then, the space occupied by family and friends; and, finally, the zone that supports the hygienic condition in the room.117 In the patient room itself, the location of the toilet and the bathroom has a major impact on the design. There is a clear tendency to increase the size of the rooms, allowing more bedside medical interventions, while just-in-time distribution systems are reducing the need for in-room storage. In surveys, two thirds of the inpatients prefer their room to have a residential feel.118 Ideally, art work and some other objects from home can contribute to bridging the gap between the institution and the private domain. Perspective of the Patient Patients’ experience during their time in an inpatient ward is shaped by personal factors such as age, length of stay, multimorbidity and level of dependency, along with the architectural layout, ward size and design and care features which make the patient more comfortable. The higher intensity of care and shorter length of stay today require an increasingly intensive patient-medical staff interaction. From the patient’s point of view it is important that the design provisions for the different types of care offer a maximum of patient safety and privacy, sufficient choice in terms of type and volume of care and an adequate level of comfort. From the perspective of economic feasibility, the challenge for ward design is to achieve a satisfactory balance among these different aspects. If patients are bedridden, this position literally determines the perspective from which they perceive their environment, something design needs to take into account. If inpatients are mobile enough to leave the room, the patient ward should offer them at least some meaningful activities; and recovering patients should be induced to gradually expand their radius and discover new parts of the ward and, ultimately, the larger environment. Ideally, they should be able to extend their reach to patios and outside gardens as a first step on the way back home.

INPATIENT WARDS

77

Functional Perspective Aging, multimorbidity and increased dependence lead to situations where more patients require staff support to get around — to get from the bed to the toilet, for instance. As patient toilets in hospitals quite often are unable to accommodate patient lifts (ceilingmounted or mobile), patients usually need to be lifted and transferred by a team of nursing staff. This is either inefficient, when the hospital opts for teams dedicated to transferring patients, or disruptive to normal processes, when the nursing staff have to interrupt their regular work in order to offer support for patient transfers. If not sufficiently trained and equipped for this task, the nursing staff themselves run the risk of occupational injury. Ward design therefore needs to include ergonomically acceptable (and financially feasible) solutions for patient transfers. Until now, ward design for inpatient care, on the one hand, and ward design for short-term care, such as 24-hour wards and day care wards, on the other, have been guided by significantly different approaches.119 As far as their position relative to other departments is concerned, individual inpatient wards are often assigned to specific medical specialties, although presently there is a trend toward accommodating all patients with a specific set of medical conditions in a multidisciplinary setting. Smaller hospitals may opt to completely abandon the traditional one-toone relationship between inpatient wards and medical specialties. Challenges for Future Design Future ward design should provide for flexibility and aim at a basic modular design accommodating both inpatient care and ambulatory care. It should be ergonomically efficient from the perspective of the nursing staff. As good visual communication between the nursing staff and patients has been demonstrated to improve patient care, ward design may move away from the hotel room type of patient room, with the bathroom as a separating element between the patient bedroom and the ward corridor. While transparency between the ward corridor and patient rooms has become a common feature in Anglo-Saxon countries, this design option is rarely found in continental European hospitals. Since patients are, on average, older, sicker and more dependent on medical care than before, and thus need to be monitored closely, room-corridor transparency will probably become more important in future ward design. This transparency should be controlled, when possible, by the patient (with adjustable blinds). Also future ward design must contribute to further reduce the patient’s length of stay. Patient mobilization has the potential to reduce the length of stay (and cost) by one day in the ICU and 1.5 days in general inpatient care. Ward design needs to incorporate features enabling a high degree of mobilization, reactivation and rehabilitation, including features supporting the patient’s toilet visits (reducing the use of bedpans), and providing integrated physical training and therapy facilities within the ward. Single-bedroom planning considerations • Minimum required space around the bed • Washbasin in patient room (instead of washbasin in patient bathroom only) • Rooming-in with a standard built-in piece of furniture or by bed-on-demand (mobile bed) • En-suite vs. shared bathrooms • Workstation in the patient room or mobile devices only (COWS or handhelds) • Patient visibility from corridor (in case of glazing between patient room and corridor) • Position of bathroom/toilet • Size, position and direction of the door • Privacy curtain (it should be possible to enter the room with the curtain drawn shut) • Storage of medical equipment (leaving medical devices in plain sight contributes to a more clinical environment) • Windows and sun screens, remotely operable by the patient • Bedside terminal or personal tablet • Dedicated TV or TV integrated with bedside terminal (optional) 78

TREATMENT AREAS

Multi-bedroom planning considerations • Required number of beds in the room • Minimum required space around the beds • Flexibility to transform multi-bed rooms into single-patient rooms in the future • Storage of medical equipment (the options to stow away devices are more limited in multibed rooms than in single-bed rooms) • Patient visibility from corridor (in case of glazing between patient room and corridor: visibility determined by position of beds vis-à-vis the corridor) • Position of washbasins/alcohol dispensers • Size, position and direction of the door • Windows and sunscreens

Single-bed room with en-suite bathroom: planning options (ill. p. 81, top and center) A Bathroom near the entrance of the patient room, resulting in: • Less patient visibility from corridor for staff (in case of glazing between patient room and corridor) • More privacy for the patient • Less daylight in corridor • Bathroom cleaning disturbs patients less B Bathroom in-between the patient rooms, resulting in: • Greater patient visibility from corridor for staff (in case of glazing between patient room and corridor) • Surplus space which can be used for support facilities (e.g. storage) • More daylight, reaching deeper into the building

For the entire inpatient ward, a layout with single-bed room and en-suite bathrooms has the following consequences: • Bedrooms are less deep, enabling wider corridors, with more diverse configurations (space for nursing stations, coffee corners, lounge, etc.). • Total building length can be increased. • Potentially better organizational options for decentralized and smaller supporting functions (storage etc.) • More visual contact between patients and staff (in case of glazing between patient room and corridor), especially in combination with decentralized nursing stations On the other hand, a layout that positions all bathrooms adjacent to the corridor has the following consequences for the ward as a whole: • Bathroom in front allows for more compact configuration (less façade = lower costs). • Maintenance can be done from the corridor (instead of in or through the patient room). A nurse is typically responsible for four to eight patients, and in a decentralized nursing concept he or she is focused mostly on processes related to those patients. Therefore, while positioning the bathroom between two single rooms results in a longer corridor, a design with the bathroom in the corner of the patient’s room could result in longer walking distances for the nursing staff. The inpatient ward needs a number of staff and support spaces: • Nursing station • Centralized per ward or • Decentralized, with multiple workstations/desks • Control room INPATIENT WARDS

79

0.9 m

1.2 m

0.9 m

0.6 m

• Flushing and cleaning space for bedpans: one or more, depending on ward size (number of beds) and dimensions[IV.2 (walking 5 - 1] distances) • Use of regular or disposable bedpans? Regular bedpans require flushing and cleaning; disposable bedpans require additional storage space and used bedpans must be disposed of. • Bed-linen storage (clean and used) • Clean bed-linen storage • Centralized storage, in-cart distribution via substations or directly 1.2 mto cabinets in 4 patient rooms • Decentralized storage • Directly to substations located at main ward/hospital junctions • Directly to cabinets (enough space for three to four changes/bed) in patient rooms • Used bed-linen storage • Decentralized substations positioned at main ward/hospital junctions, so that used bed linen can be picked up without entering the wards • Satellite pharmacy

Inpatient room with[IV.2 typical 5 - 1] components: rooming-in area (green), patient area (yellow), medical staff area (brown), patient bathroom (blue)

0.9 m

0.6 m

[IV.2 5 - 2]

Inpatient room layout The patient bed and the space around it determine the layout of the patient room; the bed in central position allows for optimal access and rapid intervention in an emergency.

0.9 m

1.2 m

4

Inpatient room configurations and their IV.2effect 1 on lines of sight/staff supervision through open doors and/or glass doors and walls. Daylight access in the corridor is also different in each configuration. [IV.2 5 - 2]

4 3

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TREATMENT AREAS

4 3

1.2 m

IV.2 2 IV.2 2

12.6 m 12.6 m

Effect on walking distances of en-suite IV.2 2positions at the patient room level bathroom

A

B

18.8 m 18.8 m

A The bathroom is positioned inside the room’s structural bay, enabling a repetitive structural bay and shorter corridor lengths; counterintuitively, this results in longer walking distances for nurses. B The bathroom is positioned in an adjacent, distinct structural bay, often leading to an irregular structural rhythm, while resulting in shorter walking distances.

IV.2 3 IV.2 3

A

B

A

B 12.6 m

18.8 m

A

B

A

B

Effect on walking distances of en-suite bathroom positions (at the nursing unit level)

52 m

71 m

A The bathroom is positioned inside the room’s structural bay, magnifying the effect on walking distances. IV.2 3 B The bathroom is positioned in an adjacent, distinct structural bay, magnifying the effect on corridor length.

A 71 m

Effect of single-patient rooms on centralized A and decentralized nursing stations (depending on the nursing intensity, the configuration can vary from two to eight patients per nursing unit; the description below is for eight patients per nursing unit) A Centralized nursing station (top center) supervising four nursing units, each with two fourpatient rooms: walking distances increase somewhat if a nursing unit is further away from the nursing station, but remain relatively short B as the structural bays required for four-patient rooms are deep. B Centralized nursing station supervising four nursing units, each with eight single-patient rooms: walking distances increase to the point of impeding the care process due to the relatively shallow structural bays; this explains the need C to decentralize nursing stations when opting for single-patient rooms for improved patient privacy. C Semi-decentralized nursing stations, each supervising two nursing units, each with eight single-patient rooms: walking distances are more manageable than in model B. D Decentralized nursing stations, each superD vising one nursing unit with eight single-patient rooms: optimal walking distances

52 m

71 m

A

B 52 m

B

A

A

B

B

C

D

INPATIENT WARDS

81

Pub lic area

Patient w ards and day treatm ent

Patient room

Patient process steps

Receiv es assistance in activ ities of daily liv ing ( ADL) Recuperates and rehab ilitates Room ing- in ( for persons accom pany ing patient and prov iding inform al care)

Medical staff process steps

Consults, treats and m onitors patient Prov ides assistance in activ ities of daily liv ing ( ADL) Supports recuperation and rehab ilitation Adm inisters m edication Takes sam ples for lab analy sis

Logistical process steps

Information flows

Prov ision at patient room lev el - Food and b ev erages serv ices - Linen and disposab les - Hospitality serv ices - Cleaning serv ices

Medical record m anagem ent Inform ation v erification ( patient inform ation, diagnostic results, m edical history , etc. ) Multidisciplinary collab oration and inform ation sharing

Departmental logistics

( Multidisciplinary ) consultation and w ard rounds Interaction w ith patient' s fam ily Patient adm ission and transfer

Patient w ard

Phy sical therapy Rest and recreation

Medication preparation Monitoring, superv ision and adm inistration

Prov ision at patient w ard lev el - Food and b ev erages serv ices - Linen and disposab les - Hospitality serv ices - Cleaning serv ices

Patient registration Patient record v erification and update Patient referrals and appointm ent scheduling Patient adm issions and transfers

Replenishm ent, storage and logistics serv ices W aste disposal, laundry and cleaning serv ices

Transition z one

Departmental logistics Patient and v isitor reception and w ay finding Hospitality serv ices for v isitors Fam ily /v isitor room s

Reception

Handov er from hospital lev el to departm ental lev el of replenishm ent, storage and logistics serv ices Drop- off point for w aste disposal, laundry and cleaning serv ices

Multidisciplinary collab oration and inform ation sharing Flex ib le w orkspaces

Hospital- level logistics Patient transfer from treatment area, other ward or home

Patient transfer to treatment area, other ward or home

Hot floor

Storage and logistics, pharm acy and m edication room s Outpatient departm ent

Process flows in the inpatient department are clustered in three functional areas: patient room, patient ward and transition zone. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.

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TREATMENT AREAS

TOM GUTHKNECHT, GURU MANJA, COR WAGENAAR

Refurbishment of the radiological department at Diakonissen Linz, Linz, Austria, DELTA, 2015

Diagnostic Imaging Advances in diagnostic imaging have constituted one of the most dramatic developments in hospital care since 1895 when Wilhelm Conrad Röntgen discovered X-rays. Diagnostic imaging has now become one of the most technologically advanced fields in medicine. In 1971, the first CT scan (which uses high doses of radiation) was performed, based on an invention by Godfrey N. Hounsfield, and in the 1970s Paul C. Lauterbur invented magnetic resonance imaging (MRI), which works on the basis of strong magnetic fields. The principles of the PET scan were first explored in the late 1950s and culminated in the PETCT scan around 2000, an innovation often attributed to David Townsend and Ronald Nutt. This was followed by the PET-MRI around 2008. Another very effective diagnostic tool in many instances is ultrasound (echography or ultrasonography), involving a relatively simple procedure which does not require large-scale equipment. All these techniques are constantly being improved. One important trend is the development of mobile imaging equipment which can be brought to the patient’s bedside (already common practice with ultrasound machines, as they have gotten cheaper, smaller and more robust). Equipment which employs electromagnetic (predominantly high-energy X-rays) and nuclear radiation, however, will continue to be housed in radiation-safe spaces, requiring patients to be transported to it. The same is true for equipment which can only be installed if specific alterations in the building are made (Faraday cages for MRIs, for instance), or which is too large or too heavy to transport. The trend toward diagnostic imaging close to the patients is nevertheless apparent here as well. Whereas only a decade ago many experts favored concentrating all heavy-duty imaging machinery at one central location in the hospital, now those hospitals that are organized around clusters of specific categories of patients or diseases often equip individual clusters with all the medical facilities they need — even if this means decentralizing the imaging facilities. Another trend that promises to change the concept of imaging departments is the merger of imaging and surgery in, for instance, (hybrid) angiography and operating rooms, cardiac catheterization and intervention rooms and hybrid operating rooms equipped with advanced medical imaging devices such as fixed C-Arms or MRI scanners, predominantly for minimally invasive surgery. Most types of patients, inpatients as well as outpatients, need diagnostic imaging at some point during their journey through the care pathway. Specialists in radiology and its various subdisciplines, the nursing staff and imaging/radiology technicians run the imaging department, which comprises a range of devices. Since these digital images — which need interpretation by highly trained specialists — can be made available anywhere, anytime, radiologists can provide assessments from other locations or from home; some hospitals have even contracted radiologists in distant countries, due to considerations of costeffectiveness or shortages of skilled labor in the local market. Spaces As in the outpatient departments, waiting areas for imaging do not need to be decentralized. Given the ubiquitous use of mobile devices, centralized waiting areas could also work well, with notifications sent to patients when it is time to report to the imaging department. In all cases, an atmosphere should be created which helps put patients at ease. The other spaces in the department are usually highly specialized, custom-built to the specifications provided by the equipment manufacturer. Perspective of the Patient From the patients’ perspective, a visit to the diagnostic imaging department can be part of any care pathway, since it serves various, quite different patient groups — ranging from trauma assessment to oncological monitoring. Patients may arrive in very different conditions: they may have been brought in after an accident, or be sedated or unconscious, or be fully conscious and feeling healthy. Some come as outpatients, while others are hospitalized and bedridden. For this reason, it is desirable to separate inpatient from 83

PET-CT facility, Deventer Ziekenhuis, Deventer, the Netherlands, De Jong Gortemaker Algra, 2008

outpatient flows.120 Specifically patients undergoing joint imaging-intervention therapies (endoscopic, laparoscopic, surgical) should be managed in separate therapy-based clusters. Different imaging technologies require different preparation processes — patients who are getting a CT, MRI or PET scan, for instance, might be administered contrast agents (iodine-based agents or isotopes) intravenously prior to the scan. Safe handling procedures are especially crucial for patients arriving with polytraumatic injuries in the emergency department. In the past, accident patients had a high risk for hospital-acquired post-accident spinal injury from being transferred to diagnostic imaging departments and lifted and turned several times on the diagnostic table in order to have X-rays taken in different positions, for instance. With today’s high resolution scanners (mainly C-arms and CT scans) in the emergency department being able to rotate at almost all angles around the emergency table, both standard localized imaging as well as full-body scans can be performed without the need to lift or turn the patient. Position Relative to Other Departments Hardly any department is as enmeshed with other hospital functions as diagnostic imaging. The location of the department is always a compromise. However, splitting up the department is not always an option, due to the relative scarcity of specialized staff needed to operate the sophisticated machines (especially radiology technicians) and the inefficiencies associated with decentralization. Should the department, or parts of it, be located close to, or integrated with, the emergency department? Should it be close to the outpatient departments, which deliver the largest workload? Should it be located close to high-tech intervention functions such as those performed in cardiology and radiology departments? Or should it be adjacent to operating facilities on the hot floor, creating, in turn, undesirable cross-traffic flows with outpatients? The likelihood of future expansion, as well as the demands placed by heavy equipment on the building structure, suggest that a location on the ground floor facing a street façade is the best option, while the wish to transfer as many of the medical procedures as possible to the immediate vicinity of the patients calls for decentralization. In order to facilitate rapid diagnostics and intervention, emergency departments always need at least a basic level of imaging equipment while maternity wards usually have integrated ultrasound facilities. Challenges for Future Design The emergence of hybrid operating rooms allowing imaging procedures during a surgical intervention is yet another step toward the integration of diagnostic imaging with other medical procedures. Ever-increasing miniaturization is not just making the current devices more mobile, but also facilitating the creation of imaging devices that can be swallowed, possibly making the entire diagnostic imaging department obsolete in the long run.

84

TREATMENT AREAS

TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Renewal of the surgery department of the Academic Medical Center (AMC), Amsterdam, the Netherlands, Valtos Architecten, 2008–2015. Daylight is provided from above via a skylight. Circle Bath, Bath, UK, Foster + Partners, 2009. Operating room with daylight

Operating Theater and Recovery Area When surgery reentered the medical world in the mid-19th century, it called for specific spaces that in later years developed into the operating theater: a suite of rooms, each with an operating table at its center. There was a preference for spaces with daylight — bright, but without direct sunlight or hard shadows. Spacious rooms with high ceilings and large glass walls facing north could provide it, and for years these were the most distinguishing features of the operating theater. Daylight was deemed superfluous when the quality of artificial illumination improved. With the introduction of special (eventually shadow-free) lamps positioned above the patient, the shift from natural to artificial light marked the beginning of the transformation of the surgery suite — also called the operating department or the operating room (OR) — from a relatively simple set of rooms into one of the most technologically advanced components of the hospital. Recent years have seen an increase in the percentage of surgeries performed in outpatient settings (up to 80Æ% of all surgical procedures in some hospitals). Surgery is becoming less invasive while imaging is becoming more interventional. The hybrid operating room allows doctors ‘(…) to see inside the body and make repairs in real time, with technology like fluoroscopy (moving X-ray machines that capture motion) and sonography’.121 Since the imaging machines tend to be quite big and need special radiation-shielding construction, the dimensions of hybrid ORs are much larger than those of conventional ones; moreover, they have to accommodate a team of technicians in addition to the surgical and anesthesiology teams. Control rooms, supply spaces, scrub areas, a locker sequence and the generator rack room may result in complex configurations for hybrid ORs.122 Remarkably, daylight has made its comeback in operating theaters, because it is still superior to artificial light in at least some ways and because it provides the staff with views to the outside world and the weather, as well as with the circadian (day and night) rhythm. The characteristics of the operating theater are to some extent generic, yielding a rather limited range of spatial options. Surgery occurs in a space filled with machinery on wheels or ceiling/wall-mounted (some taking over vital body functions during surgery), computer screens, depositories for instruments, sometimes robots, always surgical lamps and special ceilings with plenums that regulate sterile air flows, preventing contamination of the wound. Trends The design of the surgical suite is undergoing frequent adaptations in response to changing medical requirements. As the operating department is an area of high investment for any hospital, its design should contribute significantly toward an optimal workflow in order to allow the maximum return on investment; this is accomplished by maximizing the patientthroughput in these facilities. Because of the ever-present danger of infection, patients’ risks of exposure to pathogens in the OR have to be minimized. Sophisticated hygiene regimes, including clean-air-flow systems and stringent hygiene protocols, have been developed over the past decades to reduce the post-operative infection rate, as described in the well-known Lidwell study from 1982.123 It should be noted, however, that the differences in infection rates between surgeries done under high-end clean-air-flow conditions and those administering pre-operative antibiotic prophylaxis in a timely manner are statistically insignificant. Spaces Operating theaters consist of three distinct zones distinguished by the required level of sterility: a restricted area that must meet the highest hygienic norms and contains the OR; a semi-restricted area used for storage, sterilization of instruments (a ubiquitous feature in earlier designs; contemporary sterilization departments are now located in a separate area or even off-site) and the preparation of instruments; and the non-restricted spaces where, in some cases, even visitors are allowed. The position of the area where patients are prepared for surgery is one of the defining characteristics of operating theaters; the number of ORs is another. Patients can be prepared either in their own room or in designated zones in the 85

OR (even on the operating table itself). The configuration of the ORs depends on their number: single corridor (for small hospitals with a limited number of ORs), double corridor (with five to 15 ORs arranged in an I- or U-shape), the peripheral corridor with a central restricted area or the cluster type, consisting of pods, each with three to five ORs, sharing a central core. Easy-to-clean materials are needed here, which in practice results in a preference for hard, glass-like surfaces. Green was the preferred color for operating theaters until recently. The San Francisco surgeon Harry Sherman is reported to have introduced it in 1914, annoyed by the white hues that prevailed back then. Now some commentators note a trend to move away from green, which is sometimes seen as depressing.124 Perspective of the Patient Transfer and waiting zones, as well as patient preparation and anesthesia zones, must be designed to promote the reduction of patient anxiety. An important issue in this context is the reduction of exposure to noise and ‘technical’ sounds. With the increasing use of local or regional anesthesia leading to a larger proportion of patients being conscious during surgical interventions, the ambience and the design of the OR is becoming an important factor in putting patients at (relative) ease. In recent years, the trend has been to administer anesthesia and bring the patient back to consciousness in the OR, on the operating table, replacing the older practice of using a separate space outside the OR for this purpose. The focus on efficient turnaround times for the OR and haste in termination of anesthesia can be discomforting for the patient. The trade-off between the type of anesthetics and the associated specific recovery time, on the one hand, and administering (and recovery from) anesthesia, in the OR or in a separate room, on the other, needs to be made on a case-bycase basis.

Academic Medical Center (AMC), Amsterdam, The Netherlands, Architectengroep Duintjer in cooperation with Dick van Mourik, 1981–1985. Corridor in the operating department

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Functional Perspective In addition to air treatment devices a stringent hygiene concept is needed. Hygiene design efforts in the OR should focus on risk reduction around so-called pathogen communication surfaces. Such zones, which are continuously touched by many hands, include door handles, keyboards, touch screens, handles of transport and logistical items, dispenser grips for disinfectants or soaps, etc. In a successful hygiene regime potential infection chains have to be interrupted by minimizing contact surfaces and by enabling ‘contact-free’ work sequences. In recent years, the pros and cons of separating OR facilities for elective and ambulatory surgical interventions from the OR facilities for complex and acute interventions have been discussed in regard to an increased functional efficiency. The provision of a backbone OR structure with an adequate number of transfer zones and with sufficient scale for efficient utilization of the support infrastructure can enable the department to carry out both elective/ambulant and complex/acute surgical activities in an efficient manner. The advantage of a combined backbone structure is that it provides total flexibility in shifting capacity utilization dynamically from ambulant/elective to complex/acute and back, as the demand and duration of complex/acute interventions change. The complex technical environment in the OR requires that attention be paid to ‘human factors’ engineering. Architectural design should contribute to enhancing staff understanding of the technical equipment by addressing issues such as the readability of devices, spatial clarity and intuitiveness. In recent years, a range of OR layout alternatives has been explored aimed at synergies, especially for anesthesia — including the concept of an openspace OR with several operating tables in one large, open room. This concept, however, shows significant deficiencies with regard to noise and X-ray protection. Still, there are possible ways to transform existing OR structures into internally connected ORs combining the advantages of both the individual and the open-space OR.125 Efforts to improve the overall efficiency of the OR by allowing an overlapping instead of a merely sequential workflow led to the development of the so-called ‘Berner-Cluster-OR’ in 1999.126 This concept has now been realized in various hospitals in Germany, e.g. Univer-

sity Hospital Hamburg-Eppendorf. With the ‘Berner-Cluster’ model, net operating time can be increased by around 20Æ%, due to the execution of preparatory activities outside the OR. ORs can be positioned in one centrally located cluster close to the intensive care unit, but there is a strong trend toward decentralization in smaller clusters across the hospital, with each cluster being situated close to the wards.

COMPONENTS OF THE OPERATING THEATER Comprising several zones, from the most sterile (the OR and the sterile instruments preparation room) to the least sterile (preparation areas for patients, medical staff and medical samples), the operating block also has to accommodate additional functions such as transition areas, holding and recovery areas and back-office spaces. The design of all components in the operating block (OB) must be calibrated to ensure safe interventions. The main determining factors are the operating table (OT), the OR (ill. p. 95), the operating block (OB) and their position in the overall layout. There are several available choices. Operating Table (OT) Position of anesthesiologist and equipment relative to the OT/patient: The anesthesiologist is positioned close to the patient’s head, with the equipment on the main-hand side (usually right). Position of surgical team and equipment relative to the OT/patient: The position of the surgical team depends on the intervention location, which is usually toward the center of the operating table. The procedure-based trolleys (PBT) for surgical interventions need to travel the shortest distance possible through the OR and are usually positioned next to the surgical team, on the side of the OR with the instrument entrance. Position of OT relative to the patient entrance: The patient’s head is close to the patient entrance to ensure the least possible distance (and, therefore, disturbance) when the anesthesiologist goes in and out of the OR. The OT is positioned with the head close to the patient entrance, parallel to the direction of the patient bed coming into the OR. Operating Room (OR) Recommended generic dimensions are 7 × 7.5 m for most ORs, with larger or smaller configurations for specialized operating environments (for instance, 70 m2 for hybrid ORs or 36 m2 for ophthalmology). Plenum Plenum dimensions vary widely, but there is a clear trend to increase their coverage area. Their shape is usually rectangular or square, with an area of 9 m2. The OT center coincides with the center of the plenum. Entrance The entrance for the patient bed should have a width of at least 1.5 m and its position should allow for easy maneuvering of the patient bed in and out of the OR. A widely used closing system is one with a single sliding door, placed on the outer wall of the OR. Traffic and Logistics Traffic in the OR is a matter of great importance. Well-organized traffic promotes efficiency as well as the maintenance of a sterile environment. This book addresses four models of OR traffic from the point of view of process organization, hygiene and functional configuration and describes its main effects. The simplest and also oldest model allows for patient, medical staff, medical instruments and waste to share the same entrance to the OR. There are clear disadvantages to allowing contaminated and sterile traffic to use the same route. OPERATING THEATER AND RECOVERY AREA

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Nevertheless, this model can still be employed safely by using special containers for sterile instruments and transporting them in a sterilized, sealed trolley, while using other containers for waste and used medical equipment. All traffic sharing one door (ill. p. 94, A) • OR processes are linear and have a longer turnaround time. • Sterile instruments are unpacked and prepared in the OR next to the OT. • Sterile, non-sterile and contaminated traffic flows intersect each other and increase the risk of infection. • Separate, sealable containers are recommended in order to separate sterile instruments, non-sterile materials, waste, used instruments and linen. • Access to natural light from a side wall allows for better lighting schemes, better visibility, and regulation of the circadian rhythm of the medical staff. The waste traffic route can be separated from the sterile traffic route by using either a dedicated ‘sterile corridor’ to bring sterile equipment into the OR or a dedicated ‘waste disposal corridor’ to transport the waste and the used materials out of the OR. This choice entails a number of significant consequences:

Ziekenhuis Lievensberg, Bergen op Zoom, the Netherlands, De Jong Gortemaker Algra, 2009. Operating room

Dedicated waste disposal route (ill. p. 94, B) • OR processes can be executed (partially) in parallel and used instruments can be packed in the waste disposal corridor while the patient is regaining consciousness after the procedure. • Sterile instruments are unpacked and prepared in the OR next to the OT. • Sterile traffic and the waste route do not intersect. • Sterile instruments, the medical staff and the patient use the same corridor and entrance. • Sealed containers can be used to separate instruments from patient traffic during their transportation to the OR. • Direct access to natural light through a lateral wall is not possible. Separated sterile instruments route (sterile corridor; ill. p. 94, C) • OR processes can be executed (partially) in parallel and instruments can be prepared while the OR is cleaned, reducing the turnaround time. • Instruments are prepared in a separate sterile environment under a downflow (or in front of a crossflow) plenum. • Sterile traffic and the waste route do not intersect. • The medical staff, the patient and waste use the same corridor and entrance, increasing the risk of contamination. • Sealed containers are recommended to separate waste, used instruments and linen traffic from patient traffic. • Direct access to natural light through a lateral wall is not possible. In the most elaborate model, patient and medical staff traffic use a main entrance point, sterile instruments arrive by a secondary entrance point, and waste and used instruments and linen are removed via a separate waste disposal route. Separated sterile instruments and waste disposal routes (ill. p. 94, D) • OR processes can be executed (partially) in parallel, instruments can be prepared while the OR is cleaned and used instruments can be packed in the waste disposal corridor while the patient is regaining consciousness, reducing turnaround time. • Instruments are prepared in a separate sterile environment, under (or in front of) a plenum. • Sterile equipment, waste disposal and patient and staff routes do not intersect. • Access to natural light through a lateral wall is not possible.

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Decentralized Instruments Preparation Area Decentralized, shared by two ORs and positioned between the ORs (ill. p. 97, A) • Preparation of the instruments takes place in a sterile environment under a downflow (or in front of a crossflow) plenum. • Sharing the facility could result in errors due to distraction, but given the limited number of people in the preparation room (a maximum of two), chances of distraction are lower than in centralized models. • Mirrored OR configuration could lead to errors. • The niche at the entrance of the preparation room can be used for a different function, e.g. for stationing the patient’s bed instead of bringing the bed to a station further away in the operating block (logistical efficiency). Decentralized, shared by two ORs and positioned in the corridor (ill. p. 97, B) • Preparation of the instruments takes place in a sterile environment under a downflow (or in front of a crossflow) plenum. • Sharing the facility could result in errors due to distraction, but given the limited number of people in the preparation room (a maximum of two), chances of distraction are lower than in centralized models. • Mirrored OR configuration could lead to errors. • The niche at the entrance of the preparation room can be used for a different function, e.g. for stationing the patient’s bed instead of bringing the bed to a station further away in the operating block (logistical efficiency). • The lines of sight in the corridor are obstructed by the preparation rooms. • The total length of the block is shorter than in the configuration with the preparation rooms between the ORs. Decentralized, dedicated per OR (ill. p. 98, C) • Preparation of the instruments takes place in a sterile environment under a downflow (or in front of a crossflow) plenum. • Facilities are not shared, minimizing errors due to distraction. • The niche at the entrance of the preparation room can be used for a different function, e.g. for stationing the patient’s bed instead of bringing the bed to a station further away in the operating block (logistical efficiency). Centralized Instruments Preparation Area Centralized, ORs on the side (ill. p. 98, D) • Shared facilities increase the risk of errors due to distraction. • Storage area for the patient bed is placed in the corridor, in a special niche along the corridor or in a special room at the entrance to the operating block. Using a special room at the entrance to the operating block is recommended, as it reduces the risk of contamination, but this means less efficient patient and bed logistics. • One sterile corridor and two patient and waste corridors Centralized ORs in the middle (ill. p. 99, E) • Shared facilities increase the risk of errors due to distraction. • Storage area of the patient bed is placed in the corridor, in a special niche along the corridor or in a special room at the entrance to the operating block. • Two sterile corridors and one patient and waste corridor Another concern is the anesthesiologist traffic which can use a separate door or a sluice inside/outside the OR. The anesthesiologist comes in and out of the operating room at least twice per operation. Opening the door between spaces with different air pressures creates turbulence; that can result in movement of airborne particles (such as germs) into the OPERATING THEATER AND RECOVERY AREA

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sterile area and therefore lead to contamination. Using a smaller separate door in the corner helps minimize this risk. A sluice adjoining the OR entrance (or adjoining the smaller door) could eliminate this risk, but it requires additional investment and space. Smaller entrance included in the OR door for the access of the anesthesiologist • Reduces but does not eliminate air turbulence and the associated risk of infection. • Could also serve as a decentral sanitizing point (alcohol dispenser) placed at the entrance to the OR (the centralized washing station is preferably situated next to the changing room for medical staff).

Los Arcos del Mar Menor University Hospital, Murcia, Spain, Casa Solo Arquitectos, 2011. Corridor in the operating department

Sluice inside the OR • Reduces air turbulence to a negligible level, practically eliminating the risk of infection • Could also serve as a decentralized sanitizing point (alcohol dispenser) placed at the entrance to the OR. Sluice outside the OR • Reduces air turbulence to a negligible level, practically eliminating the risk of infection. • Could be used as an additional cleaning space with washbasins for the medical staff. Operating Block (OB) The operating block can be configured in multiple ways. The main layout options are described here schematically, in groups of 12 ORs, to illustrate the configuration, traffic and walking distances for the various actors. Single corridor model (ill. p. 92, A) The single corridor model arranges all the ORs along one corridor which leads to the patient preparation and recovery areas, to the medical staff preparation area and to other functional areas. • Distances covered are longer in general for patients and medical staff going in and out of the OR than in the other models. • The waste traffic has a direct, separate route. • Indirect access to daylight through a lateral wall is possible for all ORs. Cluster model (ill. p. 92, B) The cluster model groups ORs around a central instruments preparation room. Clusters can vary in size and number, but a group of four is most often used. • Access directions for medical staff and patients on their way to ORs are similar. • Waste traffic does not have a separate route. • Access to direct or indirect daylight is possible only for a limited number of ORs. • More compact layout than the single corridor model • Storage areas can be situated adjacent to the instruments preparation room, which functions as a sluice for various medical supplies. Double-loaded corridor model (ill. p. 92, C) The double-loaded corridor layout has a simple version, with storage facilities positioned separately from the ORs, and a more compact and traffic-effective one, with the storage area positioned along the corridor. • Medical staff and patients travel similar distances, though in some cases the patients must cover long distances along the corridor. • Waste traffic has a direct, separate route. • Access to indirect daylight from a lateral wall is possible. • More compact layout than the single corridor model

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Process flows in the OR complex are clustered in three functional areas: the OR zone, the preparation and recovery zone and the sluice zone. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.

Clean corridor in the middle (ill. p. 92, D) The clean corridor model is very effective in terms of traffic, since it arranges the ORs around the centralized instruments preparation area. • Medical staff and patients travel similar distances, though in some cases the patients must cover long distances to the ORs. • Waste traffic has a direct, separate route. • Access to indirect daylight from a lateral wall is not possible.

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Department logistics Transferred to and from OR and holding and recov ery areas Participates in patient v erification and surgical/anesthesia checklist w alkthrough ( holding) Undergoes post- operativ e recov ery b efore transfer to w ard

Replenishes ( at holding/ recov ery and OR lev el) - Sterile instr. and disposab les - Medication - Clean linen and other m aterials Prov ides cleaning serv ices Collects w aste and used m aterials

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Patient registration Patient record v erification and update OR and procedure inform ation m anagem ent ( OR team , surgeons, anesthesiologist, instrum ents, eq uipm ent, procedure) Checklists Patient transfers

Department logistics Patient and b ed logistics Changing into scrub s, surgical hand scrub b ing

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Patient and v isitor reception

Replenishes ( at departm ental lev el) - Sterile instr. and disposab les - Medication - Clean linen and other m aterials Prov ides m aintenance, repair and replacem ent serv ices for eq uipm ent and facilities Prov ides cleaning serv ices Collects w aste and used m aterials

Inform ation on w aiting tim es and procedure duration Inform ation for persons accom pany ing patients ( on display m onitors/telev isions and face- to- face)

Hospital- level logistics Patient transfer to OR

Patient transfer from OR to post- operative care ( patient wards or day treatment)

Patient w ards and day treatm ent

Storage and logistics, pharm acy and m edication room s Outpatient departm ent

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V II V III 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Operating room Instruments preparation room Holding area Recovery area Supervising nurse' s desk ( moveable) Planning and coordination office Sluice Staff changing rooms Staff rest area Satellite pathology laboratory and sample collection for other labs T emporary storage for ( medical) waste T emporary storage for used instruments Waiting area for accompanying persons Storage area for sterile instruments and disposables and other sterile materials Storage area for clean linen and other clean, non- sterile materials

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Patients Patients Impact of spatial differentiation (dedicated A nesthesiologists, surgeons, nesthesiologists, staff surgeons, other medical staff A other medicalASterile Sterile and clean materials and clean materials Waste and used materials Waste and used materials spaces for specific tasks) on process flow, contamination and infection risks and turnaround time Anesthesiologist Anesthesiologist

B

Anesthesiologist

A When all traffic shares one route, OR processes are linear and turnaround time is longer. Surgeon Surgeon B With a separated waste disposal route, OR processes can be executed partially in parallel. C With a separated sterile instruments route, instruments are prepared in a sterile environment under a plenum; sterile traffic and the Patient, staff, sterile/clean and w aste/used Patient, staff, sterile/clean and w aste/used m aterials traffic share the sam e route m aterials traffic share the sam e route waste route do not intersect. 1 Preparation of OR for the interv ention 1 Preparation of OR for the interv ention D With separated sterile instruments and waste disposal routes, the patient can be woken up Preparation of sterile surgical 2 Preparation of sterile surgical while the used instruments are taken2away, and instrum ents and disposab les instrum ents and disposab les sterile instruments for the next patient can be prepared while the OR is cleaned, reducing turn3 Patient arriv es in the holding area 3 Patient arriv es in the holding area 4 Patient v erification and 4 Patient v erification and around time substantially. surgical/anesthesia checklist surgical/anesthesia checklist Plenum

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Generic OR layout The Operating Table is positioned with the head close to the patient entrance, parallel to the direction of Operating the patient bed coming into the OR, Room Operating to minimize 1the effecttable of air turbulence when the 2 A dj ustable surgical lights pendant 3 Surgical anesthesiologist leaves the room (after adminis4 Medical PC with medical k eyboard, phone tering anesthesia) andmounted reenters (tosurfaces end anestheto avoid for dust ( both- wall accumulation) sia administration). The anesthesiologist Operating Room system for movement of goodsstays ( and, 5 Interlock tablepeople) sometimes, during procedure at the head12ofOperating the patient, with thetheequipment on A djA ustable surgical nesthesia trolleylights 6 Surgical 3 7 Instruments table right). The position the main-hand sidependant (usually Medical PC with medical 4 8 Procedurebased trolleyk eyboard, phone of the surgical team depends on the intervention wall mounted to avoid surfaces forto dust ( both9 Inpatient bed ( present during transfer and accumulation) from the OR, before and after the procedure) location, usually toward the middle-foot of the 5 Interlock system for movement of goods ( and, sometimes, people) during the procedure operating table. 6 A nesthesia trolley

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7.5 m

3

7 Instruments table 8 Procedure- based trolley 9 Inpatient bed ( present during transfer to and from the OR, before and after the procedure)

7

Plenum

3m

6 2

7.5 m

1

A

1

S

A rea for additional medical eq uipment depending on the medical procedure ( C- arm, heart- lung 2 machine, additional PB T s, fire extinguisher, A rea forconferencing additional video 9 medical eq uipment facilities, etc.) depending on the medical procedure 8 ( C- arm, heart- lung 2 machine, additional PB T s, fire extinguisher, 8 video conferencing 9 facilities, etc.)

3

8

2

8

S3 m

7

3

Operating Room 1 Operating table 2 A dj ustable surgical lights 3 Surgical pendant 4 Medical PC with medical k eyboard, phone ( both- wall mounted to avoid surfaces for dust accumulation) Operating Room system for movement of goods ( and, 5 Interlock 1 Operating table sometimes, people) during the procedure ustable surgical 26A A djnesthesia trolley lights pendant 37Surgical Instruments table PC with medical 48Medical Procedurebased trolley k eyboard, phone wall mounted to avoid surfaces 9( bothInpatient bed ( present during transferfor todust and accumulation) from the OR, before and after the procedure) 5 Interlock system for movement of goods ( and, sometimes, people) during the procedure 6 A nesthesia trolley 7 Instruments table 8 Procedure- based trolley 9 Inpatient bed ( present during transfer to and from the OR, before and after the procedure)

7m

3m 7m

5 4

5 4 3

A

6

2 1

Plenum

6

9

A 2

2

7

Plenum

3m

8.5 m

3m

3

8.5 m

Hybrid

Operating Room 1 Operating table 2 A dj ustable surgical lights 3 Surgical pendant 4 Medical PC with medical k eyboard, phone ( both- wall mounted to avoid surfaces for dust accumulation) Operating Room system for movement of goods ( and, 5 Interlock 1 Operating tablepeople) during the procedure sometimes, OR2layout A djA ustable surgical nesthesia trolleylights 6 Surgical pendant 3 7 Instruments table Medical PC with medical 4 8 Procedurebased trolleyk eyboard, phone wall mounted to avoid surfaces forto dust ( both9 Inpatient bed ( present during transfer and accumulation) from the OR, before and after the procedure) 5 Interlock system for movement of goods ( and, sometimes, people) during the procedure 6 A nesthesia trolley 7 Instruments table 8 Procedure- based trolley 9 Inpatient bed ( present during transfer to and from the OR, before and after the procedure)

1

S

9

A rea for additional medical eq uipment depending on the medical procedure ( C- arm, heart- lung machine, additional PB T s, fire extinguisher, A rea forconferencing additional video medical eq uipment facilities, etc.) depending on the medical procedure ( C- arm, heart- lung 8 machine, additional PB T s, fire extinguisher, 8 video conferencing facilities, etc.)

3

8

2 7

8

S3 m 3

Operating Room 1 Operating table 2 A dj ustable surgical lights 3 Surgical pendant 4 Medical PC with medical k eyboard, phone ( both- wall mounted to avoid surfaces for dust accumulation) Operating Room system for movement of goods ( and, 5 Interlock 1 Operating table sometimes, people) during the procedure ustable surgical 26A A djnesthesia trolley lights pendant 37Surgical Instruments table PC with medical 48Medical Procedurebased trolley k eyboard, phone wall mounted to avoid surfaces 9( bothInpatient bed ( present during transferfor todust and accumulation) from the OR, before and after the procedure) 5 Interlock system for movement of goods ( and, sometimes, people) during the procedure 6 A nesthesia trolley 7 Instruments table 8 Procedure- based trolley 9 Inpatient bed ( present during transfer to and from the OR, before and after the procedure)

7m

3m

Medical technician' s room ( primarily in hybrid ORs) 10 Intercom 11 Washbasin 12 A lcohol dispenser 13 Control stations 14 Server room Medical technician' s room ( primarily in hybrid ORs) 10 Intercom 11 Washbasin 12 A lcohol dispenser 13 Control stations 14 Server room

7m

11 12

11 12

13

13

10

10

13

13

14

14

Medical technician' s room ( primarily in hybrid ORs) 10 Intercom 11 Washbasin 12 A lcohol dispenser 13 Control stations 14 Server room Medical technician' s room ( primarily in hybrid ORs) 10 Intercom 11 Washbasin 12 A lcohol dispenser 13 Control stations 14 Server room

OPERATING THEATER AND RECOVERY AREA

95

OR z one

OR z one

Preparation/ recov ery z one

Operating rooms

Planning and coordination office

Planning and coordination office Sluice

Sluice

A cute and trauma patients

Post- operative recovery

Holding/ Pre- operative preparation

accompanying persons

for A Waiting cute andareaPersons accompanying Patient in Reception room/ trauma patients accompanying Sluice patients persons

IV.4 1

Persons accompanying patients

Patient in

Instr. prep. room

Storage

Sluice

Sluice

Sluice

Instr. prep. room

Storage

Post- operative Holding/ Waiting area for Preoperative preparation Reception room/ recovery

Sluice z one

Preparation/ recov ery z one Sluice z one

Operating rooms

Disposables

Sterile

Sluice instruments,

clean linen and materials

Used instr.Sluice and dirty linen

Instrument steriliz ation/ Laundry services Used

Disposables

Patient out

Sterile instruments, clean linen and materials

Typical zones, functions and process flows in the operating department

IV.4 1

Washing facilities

Staff rest area Satellite pathology lab

Sluice

Sluice

Patient out

Staff rest area

instr. and dirty linen

Waste

Washing facilities Staff changing room

Samples

Medical staff

Satellite pathology for lab Staff changing room lab analyses

Waste disposal

Lab

Waste

Samples for lab analyses

Instrument steriliz ation/ Laundry Instrument sets, disposables anddisposal other Waste services materials are transported individually or

Medical staff

Lab

in consolidated form as procedurebased trolleys ( PB T ) from the central ( sterile) storage areas via the operating department' s goods receipt.

Instrument sets, disposables and other

PB materials T / Separate are transported individually or in( sterile) consolidated form as procedurematerials

Tree diagram showing various configurations of the instruments preparation area

based trolleys ( PB T ) from the central T s or storage areas via the operating ( PBsterile) individual department' s goods receipt. instrument sets, loose instruments and x

PB T / Separate sterile ( sterile)disposables materials

IV.4 2

PB T s or individual instrument sets, loose instruments and Operating sterile room disposables x

IV.4 2

Instruments and disposables

Operating room Instruments and disposables

Plenum Instr. prep. table

Plenum Instr. prep. table

Decentraliz ed

Centraliz ed

Decentraliz ed

A

A

96

TREATMENT AREAS

Centraliz ed

B

B

C

C

D

D

E

E

A

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

A

Rinsed and pack ed used instruments, dirty linen

Dedicated waste disposal corridor

Surgeon

Surgeon

Plenum

Waste containers

Instruments steriliz ation/ Laundry services

Plenum

Anesthesiologist

Anesthesiologist

Central storage facilities for instrument sets, disposables and other sterile materials, and separately for clean linen and other clean, non- sterile materials

Patients, instrument sets, disposables and other sterile materials, clean linen and other clean, non- sterile materials

Anesthesiologist

Anesthesiologist

Plenum

Plenum

Surgeon

Surgeon

Dedicated waste disposal corridor

Rinsed and pack ed used instruments, dirty linen Waste containers

Instruments steriliz ation/ Laundry services

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

B Configuration options for the instruments preparation area A Decentralized preparation area, shared by two ORs, positioned between the ORs B Decentralized preparation area, shared by two ORs, positioned in the corridor

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

B

Rinsed and pack ed used instruments, dirty linen

Dedicated waste disposal corridor

Waste containers Surgeon

Surgeon

Plenum

Anesthesiologist

Plenum

Anesthesiologist

Patients, instrument sets, disposables and other sterile materials, clean linen and other clean, non- sterile materials

Anesthesiologist

Central storage facilities for instrument sets, disposables and other sterile materials, and separately for clean linen and other clean, non- sterile materials

Anesthesiologist

Plenum

Surgeon

Instruments steriliz ation/ Laundry services

Plenum

Surgeon

Dedicated waste disposal corridor

Rinsed and pack ed used instruments, dirty linen Waste containers

Instruments steriliz ation/ Laundry services

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

OPERATING THEATER AND RECOVERY AREA

97

C

C

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers Rinsed and pack ed used instruments, dirty linen

Dedicated waste disposal corridor

Waste containers Surgeon

Instruments steriliz ation/ Laundry services

Surgeon

Plenum

Plenum

Anesthesiologist

Anesthesiologist

Patients, instrument sets, disposables and other sterile materials, clean linen and other clean, non- sterile materials

Anesthesiologist

Central storage facilities for instrument sets, disposables and other sterile materials, and separately for clean linen and other clean, non- sterile materials

Anesthesiologist

Plenum

Plenum

Surgeon

Surgeon

Dedicated waste disposal corridor

Rinsed and pack ed used instruments, dirty linen Waste containers

Instruments steriliz ation/ Laundry services

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

D Configuration options for the instruments preparation area C Decentralized preparation area, dedicated per OR D Centralized preparation area with ORs on the side E Centralized preparation area with ORs in the middle

D

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers Rinsed and pack ed used instruments, dirty linen

Patient route and waste disposal route

Anesthesiologist

Anesthesiologist

Plenum

Surgeon

Plenum

Surgeon

Dedicated sterile corridor ( and centraliz ed instruments preparation room)

Surgeon

Central storage facilities for instrument sets, disposables and other sterile materials, and separately for clean linen and other clean, non- sterile materials

Surgeon

Plenum

Anesthesiologist

Waste containers

Instruments steriliz ation/ Laundry services

Plenum

Anesthesiologist

Patient route and waste disposal route

Rinsed and pack ed used instruments, dirty linen Waste containers

Instruments steriliz ation/ Laundry services

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

98

TREATMENT AREAS

E

Dedicated sterile corridor ( and centraliz ed instruments preparation room)

Surgeon

Surgeon

Plenum

Anesthesiologist

Plenum

Anesthesiologist

Rinsed and pack ed used instruments, dirty linen

Patient route and waste disposal route

Waste containers Anesthesiologist

Plenum

Surgeon

Anesthesiologist

Plenum

Instruments steriliz ation/ Laundry services

Central storage facilities for instrument sets, disposables and other sterile materials, and separately for clean linen and other clean, non- sterile materials

T he waste and recycling team pick s up - used instruments in closed containers and dirty linen in laundry carts - waste containers

Surgeon

Dedicated sterile corridor ( and centraliz ed instruments preparation room)

OPERATING THEATER AND RECOVERY AREA

99

TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Intensive Care Unit Intensive care unit (ICU) design is a relatively new subject. While some of the other departments, such as the wards and facility services like laundry, have a tradition reaching back to the pavilion hospitals of the 18th century and even earlier, the intensive care unit emerged only in the second half of the 20th century. The first ICU was established in 1953 in Copenhagen, Denmark in response to a polio epidemic, and the idea was subsequently adopted in the United States. However, it took some time, until the 1970s, before this innovation became more broadly accepted internationally. The initial focus of the ICU was the treatment of cardiac problems, because of the high morbidity and mortality associated with myocardial infarctions. Later on it was found that the survival rate of polytrauma patients and the treatment of multi-organ failures could be improved in the ICUs, thanks to artificial ventilation, better fluid management and more specific medication. Intensive care will remain an area of continuous technological change in the future, with the introduction of new and improved therapies, on the one hand, and the demographic shift toward an increasingly aged and multimorbid patient population, on the other. Intensive care units have, however, acquired a bad reputation. Since they are characterized by constant and very bright artificial light, absence of daylight (and therefore a disruption of the circadian rhythm) and, above all, continuous high levels of noise, they are often seen as the least pleasant places in a hospital. ‘Intensive care’, a nurse who worked in one for a time noted, ‘is, at best, a temporary detour during which a patient’s instability is monitored, analyzed and corrected, but it is, at worst, a high-tech torture chamber, a taste of hell during a person’s last days on earth’.127 Equally exaggerated of course, it has been said that ICUs might satisfy the criteria for torture as defined by the Geneva Convention.128 Even though the application of evidence-based design in the ICU is ‘just in its infancy’, it can be taken as a starting point, since ‘evidence shows that the physical environment affects the physiology, psychology and social behaviors of those who experience it’. It should also be noted that ‘pleasant surroundings for patients and staff promote increased comfort and, in some cases, improved outcomes’.129 An ICU should have efficient noise control and avoid exposing patients to bright light 24 hours a day: what is needed is a sense of ‘calm and balance’.130 Two aspects stand out in the effort to enhance patient experience: accommodating families in the ICU and providing natural light with views to the outside world. Family provides social support, but it can make the staff nervous if the spaces are inadequate and crowded; thus, architectural interventions are indispensable in this regard.131 Research carried out at one particular facility ‘demonstrated that family and patient satisfaction with ICU experience increased by 6Æ% in the new ICU environment consisting of noise-reduced, single rooms with daylight, adapted coloring and improved family facilities.’132 Natural light ‘is essential to the well-being of patients and staff’.133 ‘Natural light is one of the most comforting and familiar things you can provide in a hospital. Windows must be a part of all effective ICU and CCU designs. The height of the windows should be low enough for an optimum view so that patients can see both the ground and the sky. The idea is to admit a maximum of natural light to allow patients contact and orientation with the outside world, but the light should be controllable for sleeping.’134 Moreover, research appears to prove ‘that the design of a new facility with increased light levels and window views may have a positive impact on staff vacancy and absenteeism. Results regarding their impact on patient pain levels and staff medical errors were inconclusive; however, the data can be used as comparators for other studies on this topic.’135 An important trend is the renewed emphasis on infection control (triggered by an increase in hospital-acquired infections). Measures to combat this risk include single-occupancy rooms in ICUs, acuity-adaptable/scalable beds (fit to accommodate critical ‘intensive care’ patients as well as ‘medium care’ patients on their way to recovery), hand-washing fixtures, hygienic management, ventilation, risk assessment, safe use of potable water and clean surfaces. Research suggests that placing a copper alloy surface on six common, frequently touched objects in ICU rooms reduced the risk of HAI (hospital-acquired infections) by more than half at all study sites.136

100

TREATMENT AREAS

Glasgow Royal Infirmary, Glasgow, UK, Reiach and Hall Architects, 2011. Reception and view of intensive care unit

Four zones can be distinguished in the ICU: the patient care zone, the clinical support zone, the unit support zone and the family support zone. ‘Glass partition walls to facilitate surveillance and certain medical equipment have to be installed in an intensive care unit, but designers should try to make them as homely as they can, using natural materials and colors to soften the harshness of the environment they normally provide.’137 Perspective of the Patient Patients in ICUs are closely monitored at all times, drugs are administered if needed, and personnel — medical specialists and a specialized, dedicated nursing staff — are at hand to come to the rescue in case of calamities. ‘The ICU is the stage for many of life’s most extraordinary dramas’, to quote Kirk Hamilton who has researched the design of intensive care units.138 It is, however, a misconception to think that patients do not experience their time in the ICU intensely. Swedish studies have shown that ICU patients spend on average around 60Æ% of their time (during daytime) in a conscious state. Design efforts in intensive care must therefore pay careful attention to the patients’ needs. ICUs can cause a lot of unintended and unnecessary harm to patients, particularly to those staying longer than 14 days. Studies indicate that around 30Æ% of long-term ICU patients develop posttraumatic stress disorder (PTSD), which diminishes the patients’ ability to return to a balanced life and/or the ability to work again.139 Design interventions can help alleviate and, more importantly, prevent such harmful effects. Conditions with a negative impact on patient health are: • Continuous disorientation • Continuous illumination • Exposure to extreme noise (frequently higher than 60 dB on average)140 • Sleep deprivation • Loss of control combined with abundant alarm functions (the latter give the patient the continuous impression of being in a life-threatening situation) Considering the goal of intensive care, namely to keep the patient alive, the design of such facilities must be significantly improved in order to prevent further collateral damage to patients. Early mobilization and reactivation while the patient is still in the ICU has been shown to have a positive effect on his or her health. Studies show that mobilization, including moving the still-ventilated patient and even mobilizing the unconscious patient, may lead to an average reduction in the length of stay for long-term patients of 1.0 days in the ICU and 1.5 days in general inpatient care. This is not only a significant cost factor but also 101

considerably improves the patient’s quality of life by reducing the risk of loss of muscular tissue.141 ICU design must therefore provide sufficient space and equipment to enable the early mobilization of patients. Functional Perspective ICU care is usually differentiated into three levels: Level I — Intensive care surveillance (IMCU) Patients showing signs of dysfunction in one organ system who require continuous surveillance (monitoring) and minor pharmacological or technical support. These patients are at risk of developing one organ failure or have recovered from an organ failure and require an elevated level of attention or care. Level II — Intensive therapy (ICU) Patients requiring intensive surveillance and/or a low level of therapy for potential failure of one organ system with life-threatening conditions, organ replacement, machine-assisted ventilation or continuous dialysis. Level III — Intensive therapy (ICU) Patients requiring intensive surveillance and/or a high level of therapy for two existing or potential organ system failures with immediate life-threatening conditions, organ replacement, support systems to maintain blood circulation, machine-assisted ventilation or continuous dialysis.142 Considering the condition of patients in ICUs, noise reduction, light management and control of alarm functions must be key parameters for ICU design. Large open-space solutions accommodating several patients in one large room represent hygienic hazards and should not be adopted. Position Relative to Other Departments The intensive care unit is usually adjacent to the medium care unit, offering the possibility of using the latter to scale up when the number of patients in need of intensive care exceeds the number of beds available in the ICU. It goes without saying that ICUs are best located near those departments that accommodate most patients (at risk of) needing close observation and life support after treatment. The operating block is one of these (in the case of complex surgical interventions), the emergency department another. The position next to the operating block ensures a fast transfer to an operating room in case of life-threatening complications needing surgical intervention. In some cases, the patient can be brought into the post-anesthesia care unit (PACU) after the operation (instead of being transferred to an ICU), where he or she can be stabilized by specialized medical staff. This allows for around-the-clock supervision from multiple medical specialists, as the PACU is one of the areas nearest to the operating block. At the same time, it requires the round-the-clock presence of monitoring staff, ensuring that any change in the state of the patient is observed and, if necessary, acted upon. The optimal location of the PACU is debatable, with arguments favoring proximity/integration both to the operating block and to the ICU. Challenges for Future Design Due to efforts to reduce the length of stay in hospitals, the pressure to scale up the intensive care facilities will increase. Integration of continuous monitoring into general inpatient care is therefore probably unavoidable in order to reduce the burden on the limited and expensive ICU facilities. Future design could include the provision of a post-anesthesia care unit in addition to the ICU; it could serve as a pivot between the OR, OR recovery, emergency and the ICU. This will allow the ICU to focus better on its core activities. 102

TREATMENT AREAS

The following criteria will be important in future ICU design: • Patients’ quality of life • Early mobilization facilities • Reducing the chances of post-ICU traumatic stress disorder • Moving from horizontal design to vertical design, with e.g. the design of ceilings above patients’ beds as an element of healing design • PACU and more monitoring facilities in inpatient wards as pivots to reorganize ICU care • Management of patient fear and anxiety • Balancing health and comfort — allowing optimal supervision and monitoring with maximum comfort for the patient • Stimulating and motivating the patient to actively participate in the healing process The Patient Bed The ICU bed allows for extensive customization of the position of the patient, and it is equipped with artificial ventilation, equipment necessary for life support, feeding and for monitoring of vital functions. The medical staff should be able to move freely around the patient, with rules prescribing a minimum clear area around the patient bed. This is usually 1.8 m measured from the side of the patient bed and 1.2 m measured from the foot of the bed. This area should be free of furniture, equipment and any other obstacles, with the exception of life-support equipment. The patient should have easy access from the bed to means of communication with the medical staff. The Patient Room The patient room is the smallest module in an ICU unit. It is recommended that patients have individual rooms and visual access to direct daylight and to an exterior view, so as to minimize the incidence and effects of disorientation. In order to support patient orientation, it is necessary to include a clock and a calendar, set to show the correct time and date, in the room. The calendar, or a whiteboard, can be used to show the timetable and names of the nurses on duty. The patient room should allow for constant supervision. The nurse or the medical supervisor needs a workstation equipped with a computer allowing for monitoring vital signs and handling data input related to the patient’s condition. A washbasin and/or a sanitizing alcohol dispenser allows for easy hand-cleaning before and after consultation or intervention. A locker for the nurses should allow for localized storage of medical equipment, medication, folders, etc. The patient’s belongings could be stored in a locker outside the unit. The ICU patient usually is in such critical condition that movement outside the bed area is

Bradford Royal Infirmary, Bradford, UK, Bridger Carr Architects, ICU, 2016. The intensive care unit has 16 single rooms grouped in clusters of four, with glass partitioning walls that can be either frosty or transparent; it is endowed with a lighting system that emulates daylight and the rhythm of day and night. INTENSIVE CARE UNIT

103

rarely possible. En-suite toilets or bathrooms are therefore not necessary. However, for situations where the patient is capable of walking (or being transported) to the bathroom or when the ICU works as a stepped-care unit, a few patient bathrooms at the cluster or unit level are advisable. The Unit The ICU is usually organized in clusters of six to eight patients. This facilitates short walking distances, fast access for the medical staff, close supervision and sufficient nursing backup during emergencies. The staffing levels (e.g. nurses per bed) and levels of expertise required depend on the number of patients and the level of the ICU. Limiting the number of patients per cluster and placing it under the supervision of one team also helps to reduce the risk of contamination. Each cluster usually has a supervising nurse and an intensive care specialist. Usually one or two rooms per unit are equipped with a quarantine room with a sluice for highly infectious or very frail patients. Their position should be nearest to the elevators and transport route in order to minimize contamination risks. The sluice is meant primarily for use by medical staff members as they go in and out of the patient room; where it is also intended for use by patients, it must be wide enough to allow for the passage of the patient’s bed. The Department The ICU has a reception area for visitors, who are usually allowed to visit the patient in small numbers without rooming-in. In some cases, the ICU can accommodate family members wishing to spend the night in a designated area, usually immediately outside the unit. These spaces mostly have a homely living-room atmosphere. The medical staff discusses the condition of (and treatment plan for) the patient with family and provides psychological support either in these spaces, when necessary, or, when possible, in the patient’s room. Some diagnostic imaging can be done in the patient’s room using mobile imaging equipment, but examinations requiring MRI or CT scans are conducted in the diagnostic imaging department. Other examinations and interventions such as endoscopy, psychiatric evaluation, physiotherapy and dialysis can be performed in the patient’s room. Each unit must be equipped with a centralized washing area (next to the reception area) for medical staff and visitors. Patients are supervised by teams of nurses, who follow strict hygiene procedures when entering the ICU and who remain in the ICU during the entire shift. Therefore, staff toilets and facilities for relaxation and for deskbound work, as well as a kitchenette with a dining space, need to be part of the ICU. Other back-office facilities required in the ICU include a sterile and non-sterile storage area, a waste storage and disposal area, a satellite pharmacy and meeting rooms. Most of the necessary instruments, medical equipment, supplies and medication are either stored at a central location in the ICU or, in case of a large ICU, at decentralized locations servicing one or more clusters. Clean bed storage is organized at the departmental level to ensure clean patient transport to, for instance, the operating block or the diagnostic imaging department. The ICU can be configured in various ways of which five typical solutions are presented here: The first model (ill. p. 105, A) allows the main traffic route to go through the ICU clusters. Although it provides optimal access to direct daylight, it does create a challenge for the hygiene requirements of the ICU clusters. The ICU washing area can no longer function as a filter for patient room access and, therefore, contamination risk increases due to staff moving between the ICU clusters. Hygiene protocols have to be very scrupulously followed in order to ensure patient safety. The second model (ill. p. 105, B) distributes the IC rooms parallel to the main traffic corridor, decreasing walking distances and turnover time. In this model, however, direct 104

TREATMENT AREAS

Daylight

A 1

1 Reception/ Office and staff facilities 2 Storage and logistics, medication room

1 Main traffic route

2

2

Daylight

B

2

1

2

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Main traffic route

C

Daylight

1

1 2

2

Main traffic route

D

1

2

Main traffic route

2

Daylight

2

2

1

Typical layouts of the ICU department

Daylight

E Main traffic route

1 Reception/ Office and staff facilities 2 Storage and logistics, medication room

1

2

2

1

A Main traffic route through the ICU ward B Main traffic route parallel to (but outside) the ICU ward C ICUs form separate pavilions connected to the main traffic route D ICUs border a central patio, with the main traffic route on one of its sides E ICUs organized around a centralized control room INTENSIVE CARE UNIT

105

A Reception desk

A

C C Office and staff facilities

Reception desk

D D Office and staff facilities

C 106

Reception desk

Storag e and log istics, medication room

TREATMENT AREAS

Office and staff facilities

Office and staff facilities

Storag e and log istics, medication room

Storag e and log istics, medication room

B B

Reception desk

A Centralized monitoring station B Decentralized monitoring stations shared by two patient rooms C Individual monitoring stations D Mixed monitoring

Reception desk

Centralized and decentralized models for monitoring and supervision inside the ICU

Reception desk

Reception desk

daylight is unavailable for some patient rooms, although indirect daylight could be provided via the corridor (in case of glazing between patient room and corridor). However, moving shadows due to staff and visitor movements can be a source of confusion and distress for the patient. In the mirrored version of the model, access to daylight is restricted to the outward-facing rooms. Increasing the distance between the units and inserting a patio between them could allow some direct daylight into some patient rooms at the cost of longer walking distances. No matter what the solution, in this model some spaces in the ICU will be deprived of (direct) daylight. The third model (ill. p. 105, C), in essence a variant on the second, is reminiscent of earlier hospital plans inasmuch as it allows access to natural light by dividing the ICU into separate wings with wide patios between them. A simple version of this model distributes the ICU units along a main traffic corridor, allowing support facilities to be located on the other side of the corridor. If the department requires a large number of patient beds, the ICU units can be mirrored along the main traffic axis. In this case, support facilities need to be placed on either side of the ICU units, increasing walking distances. Another disadvantage is that the wings are short, which reduces future flexibility in case there is ever a need A to convert these spaces to other uses. Office and staff The fourth model (ill. p. 105, D) distributes the ICU around a central patio. Patient facilities rooms have access to direct daylight as well as to support facilities. In the case of larger departments, the model can be mirrored along the main traffic route. However, this complex arrangement requires a judicious distribution of vertical connections to allow for fast transportation of patients. The objective should be to ensure that connections to other departStorag e and ments are roughly equally distant for all ICU patients. log istics, medication room In the fifth model (ill. p. 105, E), all the patient rooms are arranged around a large, central control room giving all of them access to daylight. The monitoring, supervision and working areas of the medical staff and other back-office functions can be organized quite B efficiently, but have limited and indirect daylight. Using semi-transparent walls in patient Office and staff rooms increases the amount of indirect naturalfacilities light, but has the disadvantage of creating moving shadows. The diagram below illustrates four layout options for monitoring and supervision inside the ICU, and the diagram on p. 107 shows typical intensive care room components Storag e and log istics, and layout. medication room

Office and staff facilities

Storag e and log istics, medication room

1.8 m

1.8 m

1 Monitoring pendant 1 Monitoring pendant A rea for medical examination lamps A rea for medical 2 A dj ustable examination 2 A dj ustable lamps eq uipment eq uipment pendant ventilator pendant 3 A rtificial ventilator 3 A rtificial ( optional) disinfector ( optional) 4 B edpan disinfector 4 B edpan 5 Monitoring station 5 Monitoring station 1 1

1.2 m

1 Monitoring pendant 2 A dj ustable examination lamps

A rea for medical eq uipment

2

1.8 m

Intensive care room with typical components: ventilator pendant 3 A rtificial disinfector 4 B edpan specialized patient area (brown) with room( optional) 5 Monitoring station for additional medical equipment (pink), optional sluice (blue), optional family area (green), (possibly individual) monitoring station (purple)

1

1.2 m

1 Monitoring pendant 2 A dj ustable examination lamps 3 A rtificial ventilator pendant 4 B edpan disinfector ( optional) 5 Monitoring station

2

1.2 m

1.8 m

3

3

1

5

1.8 m

5

A rea for medical eq uipment

2

2

5 3

1.8 m

4

4

1 Monitoring pendant 2 A dj ustable examination lamps 3 A rtificial ventilator pendant 4 B edpan disinfector ( optional) 5 Monitoring station

4

4

A rea for medical eq uipment 1.8 m

3

1

1.2 m

2

5

ventilation equipment often suspended from the ceiling to preserve as much empty pendant 1 Monitoring floor space as possible 2 A dj ustable examination lamps

A rea for medical A rea for medical eq uipment eq uipment 1

1

A rea for medical eq uipment 2

3 A rtificial ventilator pendant 4 B edpan disinfector ( optional) 5 Monitoring station

3

1

2

3

3

1

3 5

3

3

4

A rea for medical eq uipment

2

2

2

4

1

1 Monitoring pendant A rea for medicallamps examination 2 A dj ustable eq uipment pendant 3 A rtificial ventilator 2 4 B edpan disinfector ( optional) 5 Monitoring station 4 1

1

3

A rea for medical A rea for medical eq uipment eq uipment 1.8 m

1 Monitoring pendant 1 Monitoring pendant ustable examination examination lamps 2 A djlayout 2 A dj ustable lamps Intensive care room pendant ventilator pendant 3 A rtificial ventilator 3 A rtificial The room is permanently equipped with B edpan disinfector B edpan ( optional) disinfector ( optional) 4 4 station station and 5 Monitoring 5 Monitoring standard equipment, with the monitoring

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1 Monitoring pendant 2 A dj ustable examination lamps 3 A rtificial ventilator pendant 4 B edpan disinfector ( optional) 5 Monitoring station

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A rea for medical eq uipment

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INTENSIVE CARE UNIT

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TOM GUTHKNECHT, GURU MANJA, COLETTE NIEMEIJER, COR WAGENAAR

Emergency Department In contrast to the popular myth, familiar from television shows, that the emergency ward is the scene of hectic activities, it in fact usually provides patients waiting there with a relatively calm environment. Large-scale accidents are rare exceptions to the rule. In real life, the emergency department is primarily the site of a group of processes that are not necessarily confined to clearly delineated areas. It requires separation of traffic flows, the prioritizing of patients and quick intervention — all these being functions of the location and intensity of patients’ injuries or ailments. An initial assessment (triage) separates patients into five categories: critical care (immediate need of life- or limb-saving medical intervention), emergent (risk of deterioration, time-critical medical issue), urgent (stable, in need of multiple medical investigations and assessments), less urgent (stable, in need of a simple medical investigation and assessment) and non-urgent (stable, no need for medical investigation and assessment). Emergency care usually involves a patient consultation, diagnostics, stabilization, treatment procedures and medical supervision, all at the same time. Patients, Visitors and Staff Patients arriving at the emergency department might be victims of accidents or crime. Some have medical conditions which can give rise to sudden critical issues requiring immediate attention. Other patients arrive in a critical state due to severe complications stemming from ailments that are relatively straightforward to treat but have long gone untreated (often because the patients are uninsured and cannot afford to pay for regular treatment). For them, the emergency department offers a service of last resort.143 This can also be the case with psychiatric patients, who might delay seeking medical advice because of the stigma associated with their problems. The proportion of different categories of patients is determined by many factors, ranging from urban safety and type of community to the primary care infrastructure and the accessibility of the healthcare systems, which in turn is directly related to the quality of the public health systems (or the lack of them). Returning to the example of psychiatric patients, their visits to the emergency department become especially problematic when specialized facilities for and medical staff skilled in detecting and addressing psychiatric symptoms are absent. Some patients may arrive at the emergency department by various means of transportation, while others might be brought to the hospital by family, friends and, occasionally, passersby. If patients cannot come by themselves in the usual ways, ambulances are provided for their transportation. In exceptional circumstances or in isolated areas, helicopters are used to transport doctors andÆ/or patients to or from accident sites. What all patients in this department have in common is the presumed need for immediate action. Time is of the essence, first of all in simply getting there. Then decisions have to be made concerning diagnosis and treatment, and if several emergencies occur simultaneously, the medical staff needs to prioritize on the spot — who should be assisted first and by whom? Once emergency treatment has started, there is no time to waste. One way of wasting time is transporting patients through the hospital, which is a good reason for integrating medical imaging (X-ray machines and CT scanners) in the emergency units, and also for having a dedicated emergency and trauma care specialist at hand. Spaces The emergency department can be accessed via three main routes: the central hospital reception area for all patients, a direct entrance to the department with a reception area for patients arriving by regular transportation and the ambulance entrance. Since the emergency department is an expensive facility to build and maintain, some of them have adjoining diagnosis and treatment facilities designed to handle non-life-threatening health issues outside of the normal working hours, staffed by general practitioners serving the area (primary care facilities). Accordingly, the reception area for patients arriving by regular transportation is usually accompanied by a spacious waiting area capable of serving both patients visiting the emergency department and patients visiting the adjoining primary care facility.

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The presence of several (three to four) triage rooms offers the possibility of quickly conducting triage for a large number of patients and of deciding on treatment plans. If a patient’s condition is not severe, he or she might have to wait some time for a consultation A mbulance services with the general practitioner on duty. Sprained limbs and simple fractures can be treated Critical care A cute surgical unit in a separate area with its own staff. T herapy teams When the condition is acute but non-life-threatening and needs immediate attention, Maj or trauma the patient can be directed to a fast-track diagnosis facility within the emergency departEmergency ment. This reduces waiting time for these patients, allows for the efficient separation of paA cute medical unit Mental health team department tient flows and frees up the more specialized facilities, equipment and staff to concentrate Pediatrics on the patients with life-threatening conditions. It is recommended that triage take place A cute upon arrival using standardized tools for analyzing the severity of the problem. This helps GP urgent care/ myocardial A cute A mbulatory care Walk - in center infarction determine the correct care pathway for the patient in an objective manner. Some emergenstrok e cy departments are equipped to deal with a wide variety of critical conditions such as major trauma and life-threatening illness, myocardial infarctions, strokes, acute exacerbation IV.6 1 Typical components of the emergency departof long-term illnesses, acute surgical needs or acute mental health deterioration. At others, ment of a large hospital patients with certain specific critical conditions are transported to specialized facilities, such as a dedicated stroke unit, bypassing the emergency department. Patients arriving by ambulance are usually in the most urgent need of medical attention. The stabilization and triage procedures are often performed en route by the ambulance staff and the patient is transported to the specific acute care department. The ambulance entrance must therefore be connected to all the acute and urgent treatment routes of the hospital. Critical cases, such as acute myocardial infarction, cerebrovascular accidents (strokes, CVA), suspected multi-organ failure or abdominal aortic aneurysm (AAA), might bypass the emergency department altogether and be transported, respectively, to the acute cardiac care unit (ACCU), the coronary care unit (CCU), the stroke unit, the ICU or the operating block. Surgery can be performed in a centralized operating block or in a dedicated acute surgical unit. Additional spaces that might be included in the emergency department are decontamination facilities for chemical, biological, radiological and nuclear accidents and a waiting and meeting area for ambulance staff and police. Some patients might arrive highly intoxicated or disturbed at the hospital, so that a special room ensuring sufficient security, supervision and control should be included. Main hospital b uilding Patients with acute psychiatric symptoms should be provided with a space designed to Main hospital prevent overstimulation and to prevent the patients from hurting themselves or others. In Reception entrance urgent cases children who are rushed to the emergency department follow the care pathway of an adult in the same state. Otherwise, children are best treated in the pediatrics Examination area/ Primary care department. IV.6 2 B ack office radiology The acute medical unit (AMU) is a recentSatellite development, acting as GP a bridge between the ( mainly B uck y and CT ) Waiting area emergency department andPrimary the inpatient wards for patients with an acute condition (usualcare Maj or trauma ly accounting for a third to half of all inpatient admissions). The layout of this unit and its A cute pediatric carewards. The most important differpatient rooms are similar to those of the usual inpatient B ack office Primary care and T riage ED ED ence entranceis the around-the-clock supervision by specialized medical staff. Patients usually stay A cute psychiatric unit for a maximum of 48 hours in the AMU, during which time the stabilization, diagnosis and Fast track Waiting area treatment plan are finalized. ED care The frequency and nature of visits toConsultation the emergency and treatment department varies during the CB RN course of the day, the week or the year. For example, children with injured, sprained or fracdecontamination Examination area facilities tured limbs usually arrive during daytime. Victims of violence and crime and intoxicated ED care patients arrive more often during the evening, night time and weekends. For any given loEm ergency departm ent cation, A mbulance it is usually possible to discern patterns, allowing for the forecasting of the average entrance number and types of facilities and staff required. The optimum services, size and configuration of emergency departments needs to be established on the basis of local research in order to ensure not only high quality of care, but also process effectiveness and efficiency. Diagnostic support

Inpatient departm ent Strok e unit

ICU CCU

Hot floor OR

Cardiac diagnosis and intervention ( Cardiac intervention rooms) Radiological diagnosis and intervention ( A ngio rooms)

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Diagnostic support

A mbulance services Critical care

A cute surgical unit

T herapy teams Maj or trauma Mental health team

Emergency department

A cute medical unit

Pediatrics

GP urgent care/ Walk - in center

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A cute myocardial infarction A mbulatory care

Perspective of the Patient Patients visiting an emergency department are usually either traumatized and in a state of stress and anxiety or else hardly conscious of the world around them. After treatment they are either discharged and can go home or are admitted to the AMU or an inpatient ward. The emergency department environment should be conducive to sustaining and increasing the patient’s sense of safety and reducing his or her stress — through, for example, intuitive layout, clear lines of sight and minimal noise and visual clutter.

Position Relative to Other Departments An emergency department must have a separate entrance, easily accessible by ambulance, private car and, if need be, helicopter. In order to ensure fast transfers to all acute intervention departments, the units should be physically close to each other or else connected by fast access routes. For example, the ACCU should be closely connected to the cardiac intervention facilities, CCU and ICU. Separation of patients with life-threatening conditions needing highly specialized care from other patient flows also reduces confusion and makes processes more efficient.

Main hospital b uilding Main hospital entrance

Reception

Examination area/ Primary care

IV.6 2 Waiting area Primary care

Primary care and ED entrance

A cute pediatric care A cute psychiatric unit

Examination area ED care Em ergency departm ent

Inpatient departm ent Strok e unit

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Emergency department and patient traffic routes

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Fast track Consultation and treatment

CB RN decontamination facilities

B ack office GP

Maj or trauma

T riage

Waiting area ED care

A mbulance entrance

Satellite radiology ( mainly B uck y and CT )

Hot floor OR Cardiac diagnosis and intervention ( Cardiac intervention rooms) Radiological diagnosis and intervention ( A ngio rooms) Radiology

B ack office ED

TOM GUTHKNECHT

Laboratory Department Laboratory facilities have a very low level of direct patient involvement. Samples are taken in many different locations and sophisticated transport systems enable the central laboratory department to be located far away from the sample collection facilities. While the technical integration of multiple analysis sequences has been the focus of innovation for the past few decades, the actual processing pattern has remained largely the same, with the following workflow: 1) sample taking; 2) sample analysis; 3) analysis report; 4) discharge of sample (waste). However, laboratory facilities are today on the brink of a fundamental paradigm change, which will move them from retrospective analysis toward prospective patient intervention and treatment. Trends Future laboratory services will have to form part of a highly interactive patient interface, since these services will change from simply providing diagnoses to participating in genetic cell treatment and the reintroduction of adapted cells into the patient’s body. The provision of facilities enabling the reintroduction of live cells may require intense cooperation with the intervention cluster, which will be a room equipped to carry out the full range of procedures, from diagnostics to operations. The paradigm change toward laboratory-driven, individually focused cell treatment will elevate the laboratory department from a service provider to a strategically important treatment facility with interfaces to a broad range of medical specialties. Functional Perspective The paradigm shift toward proactive cell treatment will lead to changes in laboratory department design even more substantial than those resulting from the introduction of the PCA (perchloric-acid-precipitable) cell detection method in the 1990s. Just as PCA today has become part of various detection methods, so the attached room sequences and work procedures associated with them have become basic elements of laboratory design. Laboratory spaces have to accommodate the new work sequence: 1) sample taking (cells); 2) cell analysis; 3) cell separation (selection of desirable cells); 4) genetic treatment of the selected cells; 5) augmentation of genetically adapted cells; 6) reintroduction of adapted cells to the patient’s body, maintaining high-quality hygiene standards; 7) monitoring of newly introduced cells with regard to integration, multiplication and behavior (healing). Challenges for Future Design In recent years there has been a trend toward outsourcing laboratory facilities, mainly in smaller and medium size hospitals — up to approximately the district hospital level in many countries. Considering the expected paradigm change described above, the outsourcing of laboratory facilities and the reduction of laboratory specialist staff may therefore prove to be a strategic mistake. While the treatment of certain forms of hematological cancer, along with some cell treatments in cardiology and general oncology, looks promising, it is still a long way before these treatments will become part of the standard case compensation scheme. Thus, decision makers and hospital planners find themselves in a particularly difficult situation, since it is impossible to finance spaces which are not yet part of a financial compensation scheme. The best advice would be to maintain the existing diagnostic laboratory facilities and allow for their gradual transformation in tandem with the evolution of the new techniques. Among the most significant design changes in this context will no doubt be those needed in the high security S1-, S2-, S3-laboratories in order to provide sufficient safety to allow for a reintroduction of live cells into the patient’s body without exposure to infections or other risks. Up to now, the safety focus in laboratory facilities has been on protection from hazards arising from the conditions of the cell samples. In the new treatment environment, the main safety concern will be to protect the selected and adapted cells from outside contamination. 111

REFERENCES

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Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 134.

Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 281.

2 Michael Kimmelman, ‘In redesigned room, hospital patients may feel better already’, in The New York Times, August 22, 2014.

14 Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 220.

3 Colette Niemeijer, De Toegevoegde Waarde van Architectuur voor de Zorg in Ziekenhuizen, Delft, 2012.

15 Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 4.

27 The term ‘business model’, as used here, articulates the long-term ‘license to operate’ of the organization and addresses not only quality, safety, effectiveness and consumer choice in healthcare delivery but, most importantly, describes how the hospital intends to provide value on a continued basis in the face of increasingly scarce financial, human and natural resources.

4 M. T. Roemer, National Health Systems of the World. Volume One: The Countries, New York, 1991. 5 ‘Gesundheitshäuser werden vorwiegend zu Orten der Information, der Ertüchtigung, der Beobachtung und der Prävention. Im Vordergrund stehen dabei nicht das Diagnostizieren und Therapieren, sondern die Prävention und das Verhindern von Krankheiten.’ Franz Labryga, ‘Grundlagen und Tendenzen für Planung und Bau von Gesundheitshäusern’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 47. 6 Department of Health, Health Building Note 09-02. Maternity Care Facilities, 2013, p. 10. 7 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 28. 8 Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 10. 9 ‘Trends in the twenty-first century: a catalog of trends and developments’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 372. 10 Philip Meuser (ed.), Krankenhausbauten/ Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 11. 11 ‘Preface’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 9.

16 Lawrence Nield, ‘Post-script: Re-inventing the hospital’, in Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 265. 17 Richard Cork, The Healing Presence of Art. A History of Western Art in Hospitals, New Haven, London, 2012. 18 Judith Healy, Martin McKee, ‘The role and function of hospitals’, in Martin McKee, Judith Healy (ed.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 70. 19 M. Egger, O. Razum (eds), Public Health, Berlin, 2012. 20 Healthcare at the Crossroads: Guiding Principles for the Development of the Hospital of the Future, 2008, p. 12. 21 Federico Toth, ‘Healthcare policies over the last 20 years: Reforms and counter-reforms’, in Health Policy 95, 2010, pp. 82–89. 22 Healthcare at the Crossroads: Guiding Principles for the Development of the Hospital of the Future, 2008, p. 10; Martin McKee, Judith Healy, Nigel Edwards, Anthony Harrison, ‘Pressures for change’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 49. 23 Healthcare at the Crossroads: Guiding Principles for the Development of the Hospital of the Future, 2008, p. 28; James Buchan, Fiona O’May, ‘The changing hospital workforce in Europe’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 226. 24 Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 3.

12 Healthcare at the Crossroads: Guiding Principles for the Development of the Hospital of the Future, 2008, p. 21.

25 Nick Freemantle, ‘Optimizing clinical performance’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 260.

13 Martin McKee, Judith Healy, ‘Investing in hospitals’, in Martin McKee, Judith Healy (eds.),

26 Martin McKee, Judith Healy, ‘Future hospitals’, in Martin McKee, Judith Healy (eds.),

112

28 ‘Principles. New paradigms in a new century’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 25. 29 The term ‘patient care pathway’ as used in this book is a sequence of steps — appointments, tests, interventions, stays, etc. — that a patient goes through for the diagnosis and treatment of a specific disease. 30 Martin McKee, Judith Healy, Nigel Edwards, Anthony Harrison, ‘Pressures for change’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 41. 31 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 22. 32 Cor Wagenaar, ‘The hospital and the city’, in Christine Nickl-Weller, Hans Nickl (eds.), Healing Architecture, Salenstein: Braun Publishing, 2013, pp. 124–147. 33 Antonio M. Gotto, ‘Foreword’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 6. 34 Johan van der Zwart, Building for a Better Hospital. Value-Adding Management and Design of Healthcare Real Estate, Delft, 2014, p. 109. 35 Pierre Wack, ‘Scenarios: shooting the rapids’, Harvard Business Review, November 1985. 36 ‘A century of medical records’, March 19, 2010. http://onhealthtech.blogspot.de/2010/03/centuryof-medical-records.html; Dana Sparks, ‘Dr. Henry Plummer, Mayo’s ultimate renaissance man’, in Mayovox, April 1989. 37 John Posnett, ‘Are bigger hospitals better?’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, pp. 114, 115.

38 Judith Healy, Martin McKee, ‘The role and function of hospitals’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 68. 39 Healthcare at the Crossroads: Guiding Principles for the Development of the Hospital of the Future, 2008, p. 12. 40 P. Boluijt, M. J. Hinkema (eds.), Future Hospitals: Competitive and Healing, Utrecht, 2005. 41 John Worthington, ‘Managing hospital care: lessons from workplace design’, in Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 49. 42 Peter Swinnen, Pilootprojecten Onzichtbare zorg. Innoverende zorgarchitectuur, Brussels, 2012. 43 Jeff Hardy, Ron Lustig, ‘No hidden patient’, in HealthcareDesign, June 30, 2006. Cf. also: G. van der Wal, Grote intensive care-afdelingen werken continu aan kwaliteit, Utrecht, September 2011, p. 5. 44 Massimiliano Panella, Kris Vanhaecht, ‘State of the art of research in care pathways: do care pathways work?’ in International Journal of Care Pathways, vol. 16, no. 31, 2012. 45 Kris Vanhaecht, The Impact of Clinical Pathways on the Organisation of Care Processes, Ph.D. dissertation, Leuven, 2007, p. 149.

51 Department of Health, Health Building Note 09–02. Maternity Care Facilities, 2013, p. 4. 52 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 183. 53 Department of Health, Health Building Note 09–02. Maternity Care Facilities, 2013, p. 37. 54 Roger Ulrich, ‘Views through a window may influence recovery from surgery’, in Science, vol. 224, 1984, pp. 420–421. 55 Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 5. 56 Cited in D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An Evidence- Based Approach, Oxford: Architectural Press, 2010, p. 4. 57 Cited in D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An Evidence- Based Approach, Oxford: Architectural Press, 2010, p. 4. 58 D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An EvidenceBased Approach, Oxford: Architectural Press, 2010, p. 4. 59 ‘Trends in Healthcare Architecture’, in Facility Care, September 2009, p. 16.

46 Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 285.

60 D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An Evidence Based-Approach, Oxford: Architectural Press, 2010, p. 4.

47 Department of Health, Health Building Note 09–02. Maternity Care Facilities, 2013.

61 Fiona de Vos, Building a Model of Holistic Healing Environments for Children’s Hospitals. With Implications for the Design and Management of Children’s Hospitals, New York, 2006, p. 4.

48 Department of Health, Health Building Note 09-02. Maternity Care Facilities, 2013, p. 8. 49 T. de Neef, C. W. Hukkelhoven, A. Franx with E. Everhardt, ‘Uit de lijn der verwachting’, in NTOG — Nederlands Tijdschrift voor Obstetrie en Gynaecologie, vol. 122, no. 10, 2009, pp. 341–342. This study found that although 90Æ% of deliveries in 2007 were intended to take place outside the hospital (45Æ% at home and another 44Æ% at community maternity centers), 73Æ% of all deliveries eventually took place in hospitals, quite a few of them involving risky transfers during labor. 50 Department of Health, Health Building Note 09–02. Maternity Care Facilities, 2013, p. 10.

62 Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 5.

65 Phil Leather, Diane Beale, Angeli Santos, Janine Watts, Laura Lee, ‘Outcomes of environmental appraisal of different hospital waiting areas’, in Environment and Behavior, November 1, 2013, p. 862. 66 H. Dalke, P. J. Littlefair, D. L. Loe, Lighting and Colour for Hospital Design: a Report on an NHS Estates Funded Research Project, London, 2004. 67 Jin Gyu Park, ‘Environmental Color for Pediatric Patient Room Design’, Ph.D. dissertation, Texas A&M University, 2007, p. iii. (Remarkably, the use of simulation techniques instead of small pieces of colored paper is seen as a methodological innovation; no reference is made to the groundbreaking work of the Hungarian scholar Antal Nemcsics, summarized in his book: Antal Nemcsics, Colour Dynamics. Environmental Colour Design, Budapest, 1993.) 68 Blair L. Sadler, Jennifer R. Dubose, Elileen B. Malone, Craig M. Zimring, ‘The business case for building better hospitals through evidencebased design’, in Healthcare Leadership. White Paper Series. Evidence-Based Design Resources for Healthcare Executives, September 2008. 69 Blair L. Sadler, Leonard L. Berry, Robin Guenther, D. Kirk Hamilton, Frederick A. Hessler, Clayton Merritt, Derek Parker, ‘Fable hospital 2.0: the business case for building better healthcare facilities’, in Research Paper No. 2012–67, Mays Business School, Texas A&M University. Reprint from The Hastings Center Report, volume 41, no. 1, January–February 2011. 70 ‘Principles. New paradigms in a new century’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 17. 71 D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An Evidence-Based Approach, Oxford: Architectural Press, 2010, p. 7. 72 D. Kirk Hamilton, ‘Bridging design and research’, in Herd 1, 2007, p. 29.

63 Leonard L. Berry, Derek Parker, Russell C. Coile, D. Hamilton, David D. O’Neill, Blair L. Sadler, ‘The Business Case for Better Buildings’, in Frontiers of Health Services Management, vol. 21, no. 1, 2004, pp. 3–24.

73 Ricardo Codinhoto, Evidence and Design: An Investigation of the Use of Evidence in the Design of Healthcare Environments, Salford, 2013, p. 208.

64 Charles Jencks, ‘Maggie Centers and the Architectural Placebo’, in Cor Wagenaar (ed.), The Architecture of Hospitals, Rotterdam: NAI Publishers, 2006, pp. 448–459.

74 Ricardo Codinhoto, Evidence and Design: An Investigation of the Use of Evidence in the Design of Healthcare Environments, Salford, 2013, p. 211.

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86 J. Abram, ‘The filter of reason: experimental projects, 1920–1939’, in J. Abram, T. Riley, The filter of reason, New York, 1990, pp. 52–62. 87 I. Rosenfield, Hospitals. Integrated Design, New York, 1947. 88 N. Mens, A. Tijhuis, De architectuur van het ziekenhuis. Transformaties in de naoorlogse ziekenhuisbouw in Nederland, Rotterdam 1999, p. 107. 89 Paul W. James, William Tatton-Brown, Hospitals: Design and Development, London: The Architectural Press, 1986. 90 Derek Stow, ‘Transformation in healthcare architecture: from the hospital to a healthcare organism’, in Sunand Prasad, Changing Hospital Architecture, London: RIBA Publishing, 2008, p. 16. 91 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 15. 92 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 37. 93 For building forms cf. also Bert Bielefeld (ed.), Planning Architecture. Dimensions and Typologies, Basel: Birkhäuser, 2016, pp. 386–387. 94 P. G. Luscuere, ‘Concurrentie in de zorg: de rol van duurzaamheid, flexibiliteit en andere ambities’, in P. Luscuere (ed.), Concurrentie in de zorg: consequenties voor gebouw en techniek, Delft, 2008, pp. 37–50; P. G. Luscuere, ‘Flexibel, duurzaam en integral ontwerpen’, in J. W. Pleunis (ed.), NVTG BouwAward 2007: exploitatiegericht bouwen in de zorgsector, Blaricum, 2007. 95 Jonathan Hughes, ‘Hospital-City’, in Architectural History, 40, 1997, p. 280. 96 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 120. 97 Mies van der Rohe, cited in Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 10. 98 Judith Healy, Martin McKee, ‘The role and function of hospitals’, in Martin McKee, Judith Healy (eds.), Hospitals in a Changing Europe, Buckingham: Open University Press, 2002, p. 70.

99 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 10. 100 Stephen Verderber, Innovations in Hospital Architecture, New York, 2010. 101 cf. chapter on circulation spaces in Sylvia Leydecker, Designing the Patient Room: A New Approach for Healthcare Interiors, Basel: Birkhäuser, 2017. 102 Janet R. Carpman, Myron A. Grant, Design that Cares. Planning Health Facilities for Patients and Visitors, San Francisco: Jossey-Bass, 1993 (second edition 2001). 103 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 106. 104 Franz Labryga, ‘Grundlagen und Tendenzen für Planung und Bau von Gesundheitshäusern’, in Philip Meuser (ed.), Krankenhausbauten/ Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 49. 105 ‘Public spaces in healthcare can have a big impact if properly designed’, in Healthcare Facilities Today, March 25, 2013. 106 M. McCarthy, ‘Healthy Design’, in The Lancet, Vol. 364, July 2004, p. 405. 107 David Allison, ‘Hospital as a city. Employing urban design strategies for effective wayfinding’, in Health Facilities Management, June 2007, p. 61. 108 ‘Ambulatory care design, professional offices, and bedless hospitals’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 250. 109 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 140. 110 Peter Pawlik, Linus Hofrichter, ‘Die Krankenhausambulanz’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 67.

111 Franz Labryga, ‘Der Pflegebereich’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 84. 112 Franz Labryga, ‘Grundlagen und Tendenzen für Planung und Bau von Gesundheitshäusern’, in Philip Meuser (ed.), Krankenhausbauten/ Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 39.

in the joint after total hip or knee replacement: a randomised study’, in British Medical Journal, 1982/7, 6334, pp. 10–14. 124 ‘Surgery facilities’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 174. 125 Tom Guthknecht, ‘Kostenreduktionen im baulichen und betrieblichen Operationsraumkonzept‘, in Krankenhausumschau, no. 10, 1997.

113 Michael Kimmelman, ‘In Redesigned Room, Hospital Patients May Feel Better Already’, in The New York Times, August 22, 2014.

126 Tom Guthknecht, ‘Schneller und effizienter im OP: Kostenreduktionen mit dem Berner Modell der OP-Cluster‘, in Krankenhausumschau, vol. 68, no. 9, 1999.

114 Elisabeth Rosenthal, ‘Is this a Hospital or a Hotel?’, in The New York Times, September 21, 2013.

127 Kristen McConnell, ‘Diary of an intensivecare nurse’, in The New York Post, December 9, 2012.

115 Susanne Lieber, ‘Check-up mit Aussicht’, in Baumeister, B8, 2009.

128 Maria Deja, Head of Intensive Care and Anesthesiology at Charité, Berlin, Lecture at ETH Zürich, October 12, 2012.

116 Terri Zborowsky, Lou Bunker-Hellmich, Agneta Morel, ‘Centralized vs. decentralized nursing stations’, in Healthcare Design, October 3, 2010. 117 ‘The patient care unit’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 240. 118 Franz Labryga, ‘Der Pflegebereich’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 80. 119 The ISO-TR 12296 2012, Ergonomics – Manual handling of people in the healthcare sector, outlines the spatial and technical requirements for a safer and more efficient working environment of wards. http://www.iso.org/iso/ catalogue_detail.htm?csnumber=51310. 120 ‘Diagnostics’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 154. 121 ‘All in one place’, in Metropolis. Architecture Design, October 2011, p. 42. 122 Catherine Gow, Brenda Byrd, ‘Redefining the operating room’, in Healthcare Design, August 20, 2013. 123 O. M. Lidwell, E. J. Lowbury, ‘Effect of ultraclean air in operating rooms on deep sepsis

129 D. R. Thompson et al, ‘Guidelines for intensive care unit design’, in Critical Care Medicine, vol. 40, no. 5, 2012, pp. 1587, 1590. 130 Doug Bazuin, Kerrie Cardon, ‘Creating healing intensive care unit environments. Physical and psychological considerations in designing critical care areas’, in Crit Care Nurs Q, vol. 34, no 4, 2011, p. 259. 131 Mahbub Rashid, ‘Environmental design for patient families in intensive care units’, in Journal of Healthcare Engineering, vol. 1, no. 3, 2010, p. 390. 132 ‘Effect of intensive care environment on family and patient satisfaction: a before-after study’, in Intensive Care Med, 39, 2013, p. 1632. 133 D. R. Thompson et al, ‘Guidelines for intensive care unit design’, in Critical Care Medicine, vol. 40, no. 5, 2012, pp. 1587, 1589. 134 ‘Critical care’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 198. 135 ‘The impact of daylight and views on ICU patients and staff (CEU)’, in Herd, March 1, 2012. 136 Jurdene Bartley, Andrew J. Streifel, ‘Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit?’, in Critical Care Medicine, vol. 38, no. 8, 2010, suppl.; ‘Copper

surfaces reduce the rate of healthcare-acquired infections in the intensive care unit’, in Chicago Journals, Infection Control and Hospital Epidemiology, vol. 34, no. 5, May 2013. 137 Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 203. 138 D. Kirk Hamilton, Mardelle McCuskey Shepley, Design for Critical Care. An Evidence-Based Approach, Oxford: Architectural Press, 2010, p. xv. 139 Craig R. Weinert et al., ‘Health-related quality of life after acute lung injury’, in American Journal of Respiratory and Critical Care Medicine, vol. 156, no. 4, 1997, pp. 1120–1128; M. Deja et al., ‘Social support during intensive care unit stay might improve mental impairment and consequently health-related quality of life in survivors of severe acute respiratory distress syndrome’, in Critical Care, vol. 10, no. 5, 2006, p. 147. 140 A. J. Salandin, ‘Noise in an intensive care unit’, in Journal of the Acoustical Society of America, vol. 130, no. 6, 2011, pp. 3754–3760. 141 D. M. Needham, ‘Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function’, in JAMA, vol. 300, no. 14, October 8, 2008, pp. 1685–1690; M. S. Herridge, Canadian Critical Care Trials Group et al., ‘One-year outcomes in survivors of the acute respiratory distress syndrome’, in New England Journal of Medicine, vol. 348, no. 8, 2003, pp. 683–693. 142 Maria Deja, Head of Intensive Care and Anesthesiology at Charité, Berlin, Lecture at ETH Zürich, October 12, 2012. 143 ‘The emergency unit’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 116. 144 Ernst and Peter Neufert, Architects’ Data, fourth edition, Chichester, West Sussex: Wiley-Blackwell, 2012, p. 291. 145 Bert Bielefeld (ed.), Planning Architecture: Dimensions and Typologies, Basel: Birkhäuser, 2016, p. 392. 146 Bert Bielefeld (ed.), Planning Architecture: Dimensions and Typologies, Basel: Birkhäuser, 2016, p. 395.

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General Hospitals

A general hospital is functionally divided into areas for consultation and diagnostics, therapy and treatment, inpatient care, laboratories, pharmacy, administration, public services and logistical housekeeping, waste disposal and maintenance services. In addition, most general hospitals have an emergency department. All areas are operationally separate but linked by short horizontal and vertical connections.144 The logistics and the organization of patient flows should contribute to improvements in healthcare delivery, safety and patient friendliness, as well as to good operational performance. General hospitals represent the majority of medical facilities. The ongoing transformational developments in healthcare will deeply impact them. In most OECD countries, many of them may even become superfluous from a public health point of view. In response to developments in medical technology, increasingly digital care pathways, the emphasis on patient empowerment, transparency in medical outcomes and satisfaction rates, and the need to bridge the gap between prevention and crisis management, many general hospitals will strive to replace large parts of their existing facilities by smaller, tailor-made but flexible buildings accommodating a cluster of related therapies. As a result, there is a marked trend towards the redistribution of medical facilities: large, supra-regional, specialized clinics providing complex, high-risk, technologically advanced treatments on the one hand, and small community health centers providing low-risk, relatively simple, high volume treatments on the other. While networks of these specialized clinics and community health centers slowly evolve, general hospitals will continue to play an important role in healthcare delivery.

Site plan with ground floor

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Circle Bath

Architect

Foster + Partners

Bath, UK

Client

Circle/Health Properties Management Ltd.

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Completion

2009

Floor area

6,400 m2

Capacity

28 beds

With only 28 beds for non-emergency medical treatment, Circle Bath is a very small facility. Its initiator, the private health provider Circle, strives to usher in a revolution in healthcare. Anticipating an influx of patients from the National Health Service, the investment should partly be recouped from public money. This requires the provider to offer medical services that meet the standards of the public system at similar costs. Prospective patients, therefore, should prefer Circle Bath to the usual large-scale medical facilities run by the state. Besides the level of the medical processes it offers, architectural features that one would expect in a five-star

First floor plan

boutique hotel rather than in a hospital are the most striking qualities of Circle Bath. Situated 9 km outside the center of Bath, the hospital overlooks an industrial site and green Somerset landscape. Like a hotel, it attracts users from the wider region, not only from the immediate vicinity. Its architectural features make quite clear that the building has nothing in common with the nearby industrial boxes, its most striking aspect being the oblong, stretchedout first floor, an aluminum-clad box on top of a recessed ground floor with large glass walls alternating with parts covered in black panels:

the box appears to float above the landscape. Underneath, the hidden third floor accommodates the ‘hot floor’, the most salient part of which is an operating theater with a glass wall facing a small garden. The atmosphere generated by high-tech medical equipment designates the basement as the part that most resembles a classical hospital. The consultancy rooms and the outpatient department are located on the ground floor, facing south. Here, generic spaces prevail: special equipment needed for specific medical procedures is not fixed to the room, but mounted on wheels. The absence of designated rooms guarantees maximum flexibility. The shiny

box on top contains the patient wards: 28 single rooms with an en-suite bathroom, a covered balcony set back within the box that allowed the architects to provide all patient rooms with a small herb garden. Set against the interior wall, a chair for visitors occupies a place that can easily accommodate a bed, in case visitors wish to spend the night in the hospital. There is a physiotherapy suite and nine outpatient consultation rooms. Patient rooms are furnished to a high standard, with an en-suite walk-in shower room, pull-out guest bed and a warm color palette of ochre and rust. Natural

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The main foyer with its characteristic, hotel-like ambiance | Transparent white curtains filter the natural light that floods the foyer via circular skylights | Operating theater with daylight | The exterior of the illuminated building in the snow

light is maximized and natural materials were used wherever possible. The four operating theaters are fitted with the latest technology and, unusually, admit daylight. The logistics layout matches the hospital’s functional zoning in its clarity and simplicity: the entrance leads straight to a covered central court that provides visual connections from all parts of the building. This makes the use of way-finding and signage systems superfluous and prevents the need for long corridors. Enhanced by its small scale, Circle Bath’s clear layout, simple logistics and hotel-like atmosphere should point toward a future dominated by similar high-quality

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mini-hospitals which in the long run may establish themselves as nodes in new healthcare networks.

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Butaro District Hospital

Architect

MASS Design Group

Butaro, Rwanda

Client

Rwandan Ministry of Health; Partners In Health/Inshuti Mu Buzima

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Completion

2011

Floor area

6,040 m2

Capacity

140 beds

It is hard to tell which aspect of the district hospital is most fascinating: its elegant design, the humanitarian ideals that inspired it or the involvement of the community in order to get it built. US $ 553,800 were spent on local labor, providing employment for over 4,000 people who first excavated the site and were then engaged in construction work. The project was supported by Partners In Health (PIH), an organization founded by Dr. Paul Farmer and Ophelia Dahl in 1987. Originating in the liberation theology movement, PIH’s aim is to bring healthcare to the world’s poorest. For the Butaro District Hospital, the Rwandan Ministry of Health teamed up with

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Partners In Health and the Clinton Foundation in 2007. Situated on a high hill that formerly housed military barracks, the hospital has been conceived as a collection of buildings that form a medical campus. The hospital has 140 beds, an outpatient cancer infusion center, housing for doctors and nurses and ample landscaped areas for the patients, their families and staff to enjoy. Hygiene and infection control were the building’s primary design criteria. Specifically targeting airborne agents spreading infectious diseases, the design integrates a sophisticated system of

natural ventilation with louvered windows that is supported by large industrial-grade fans that increase airflow and germ-killing UV lamps. Since hospital air is seen as the main cause of nosocomial diseases, it has to be continually replaced by fresh air from outside. The system refreshes the air 12 times per hour, meeting the minimum requirements of the World Health Organization. The entire building is designed to perform even during power outages. Since overcrowded corridors increase the risk of infections, hallways were minimized. The principal traffic infrastructure makes full use of the open spaces between the separate volumes,

connecting several of them with covered pedestrian walkways and waiting spaces. The hospital’s dominant architectural feature is the use of dark, volcanic stone, a local material whose application to a building façade was pioneered at Butaro, resulting in beautifully textured walls. The seemingly unstructured, rough pattern of the stones, which are stacked with minimal use of mortar, offers a striking contrast with the neat, rectangular openings of windows and doors, and with the plastered walls, the ceilings and the floor. Color is used to create bright accents throughout the building.

BUTARO DISTRICT HOSPITAL

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PUBLIC

PUBLIC

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Private Hospital

In the history of healthcare architecture, Lille Architect

Villeneuve d'Ascq

Jean- Philippe Pargade

plays a remarkable role, Paul Nelson's rejected

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Generale de Sante (operator),

as landmarks of the new ways of thinking that

lcade Sante (owner)

were explored in the 1930s, Likewise, the 225-bed

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2012

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Lille, France

private hospital designed by Jean-Philippe two older facilities, Before thinking about the specialized in programming, prompting them to define new ways of working, Convincing the staff that it would pay off to actively engage in this process, the hospital board managed to use their

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EXPLORATIONS FONCTIONNELLES

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R+3 Hospitalisation Axonometric diagram

Main façade at night | Rear façade | Façade detail, showing the use of color

expertise to define which of their professional skills cannot be transferred to other staff and how to form operational units that can perform the specific tasks assigned to them. The building should accommodate these units wherever their services are needed. Situated between a residential area and a commercial zone, the architecture pays reference to both, its size apparently negotiating between the scale of the boxes and that of the houses in the periphery of Villeneuve d’Ascq. The design language of the building is clearly that of modernism, but the black bricks that dominate

most of the exterior pay tribute to local vernacular architecture. Pargade, winner of the design competition, made a rectangular box pierced with windows that incorporate a floral printed pattern. They form a pictorial composition that strengthens the visual image of the hospital. The most remarkable feature of the ground floor is a glazed gallery that is accessible from the main, two-storied entrance hall that emulates a hotel lobby. Inserting small interior gardens allows natural light to pervade the entire building, also illuminating the operating theaters. With ten operating theaters and 225 inpatient beds, 42 of them in the maternity ward, the

hospital appears to have the proper size for a facility that is specifically intended as a node in a gradually evolving network. The hospital also includes a remarkably modest outpatient clinic with only 30 beds. The general layout of the three floors is very similar, the main principle being that of a geometrical, compact comb. The horizontal organization of the medical procedures allows for proximity and visibility between the departments and reduces the need for traffic and transportation. On the ground floor the imaging and consultation spaces are located on the front side of the building; radiotherapy, chemotherapy, pharmacy, the logistical services and the

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Views toward the entrance from the hall | Circulation spaces | Patient rooms

restaurant line the back façade, and the emergency department occupies the west side. The first floor accommodates the maternity department and outpatient functions on one side and on the other obstetrics and operating theaters. Surgery is located on the second floor, cardiology on the third. Soft colors dominate the interior. Different levels of hotel services are being offered, the most luxurious rooms being equipped with a sleeping couch for visitors; compared to the previous facilities, the number of single bedrooms has increased. Meals can be ordered à la carte. The signage system has been designed by Dominique Pierzo Conseil and is similar to

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systems used in airports. The wayfinding system is based on numbers – a simple and effective means that prevents the use of incomprehensible medical terms and avoids the confusion associated with changing names of departments. The character of the new building can be described in four words: modern, aesthetic, functional and technological; the hospital board consistently refers to it as ‘an outil’, a tool. This tool is an important step toward redefining the hospital landscape of tomorrow.

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Extension Kolding Hospital Kolding, Denmark

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Architect

Schmidt Hammer Lassen Architects with Creo Architekter

Client

Region Syddanmark

Completion

2016

Floor area

32,000 m2 (extension)

Capacity

300 beds

Danish hospital architects are credited for being among the first to develop alternative typologies for the bulky, large-scale, high-rise models that became popular in the 1950s. The horizontally organized structures that replaced them soon found their way to other countries. The existing hospital in Kolding, Jutland, is a typical example: a central street connects three blocks, each of them organized around a central courtyard, with patient wards on one side and medical departments on the other. In a thorough redistribution of healthcare facilities, the Danish government opted for a combination of centralized, relatively large hospitals supplemented by a network of

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health centers. Kolding has been designated as a facility that will concentrate upscale medical functions that serve the wider region. In this rural area, a 300-bed facility was deemed sufficient. Cooperating with Syddansk University, Kolding also offers educational programs for medical students and nursing staff. Its function as a node in a healthcare network required a complete reconstruction and extension of the existing building. It involved a radical departure from the original structure that did not have any visual hierarchy: every part had been planned in the same way and added to the other volumes along the central spine. The architects replaced

the patient wards by a long-stretched slab above the central corridor, a solution reminiscent of the classical matchbox-on-a-muffin typology. Then they added an emergency ward on one side, next to a new spacious entrance hall. The main entrance leads to the original main traffic artery. Its glazed roof disguises its limited height of only two floors and provides a view on the superstructure. No vertical traffic is needed to reach the medical departments – the hot floor is situated on one side of the central spine, the outpatient wings on the other. Wayfinding is improved by the strategic design decision of relocating the main entrance from the ‘long end’ of the struc-

ture to a more central position midway. This move is associated with the provision of a sequence of public spaces – from the entrance plaza under the welcoming portico one moves through the sky-lit foyer to the lifts. Here the visitor is taken to the inpatient department on top of the building. Four atria break down the scale of the 180 m long structure, allow for splendid views toward the surrounding landscape while accommodating common functionalities like nurse team stations and patient eating/relaxation facilities. All patient wards are made up of single bedrooms with bathroom and toilet as well as personalized flat screens.

EXTENSION KOLDING HOSPITAL

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Site plan and ground floor

Waiting area in the hall with sculptured façade | View toward the building across the open spaces that separate the wings of the hospital

AZ Groeninge

Architect

Baumschlager Eberle Architekten

Kortrijk, Belgium

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Client

AZ Groeninge vzw

Completion

2010 (phase 1)

Floor area

38,054 m2

Capacity

385 beds

For the Belgian city of Kortrijk, Dietmar Eberle of the renowned firm Baumschlager Eberle Architekten designed a hospital that replaced four existing facilities. Therefore, not surprisingly, its most distinguishing feature is its enormous scale: it has the dimensions and the complexity of a small city. It occupies a site of 15 hectares; the total length of the façade is no less than 1.5 km, a consequence of the decision to design a low-rise complex of only three floors. Obviously, a building this size could not possibly be integrated in the historical urban tissue of Kortrijk, and even in the peripheral site it now occupies it is bound to ignore its physical context: a park-like landscape

Sections

Examination room | Second floor corridor

alternating with business parks and logistical facilities located near the network of highways that marks the border region with France. Acknowledging that a large-scale structure like this can best be designed as a uniform, introverted complex, Eberle, winner of a competition held in 1999, opted for a grand architectural gesture, a striking landmark that is going to be realized in two phases. Tom Guthknecht assisted in defining the internal distribution of the medical functions and their spatial relations. The layout comprises four volumes fanning outward from a central part that accommodates the hot floor. These four outer wings and the central part each

enclose a courtyard. The entrance is situated between two wings; facing south, it leads to a two-storied hall that is to act as the building’s central traffic node. Since the central wing contains the hot floor, most people entering the building here have to be diverted around it. The main traffic routes have been designed as elongated corridors, most of which are placed in the center of the wings. Daylight is provided by relatively small interior public spaces that face either one of the courtyards or the landscape outside the building. Contrary to what one might expect in a hospital as vast as Groeninge, public facilities such as shops and restaurants have

been kept within bounds. The overriding quality of the hospital is that of a contemplative environment reminiscent, in that respect, of medieval monasteries with their enclosed monastic gardens. The most conspicuous aspect of the architectural design is the façade. It is characterized by the use of uniform load-bearing concrete elements, oriented in such a fashion that excessive direct sunlight is prevented in the interior. Consequently, the functional configuration is not apparent from the exterior, the overall impression being that of a monolithic concrete sculpture. In the second phase, 2012-2017, 77,663 m2 and 675 beds were added.

AZ GROENINGE

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Undulating wall with orange brick and off-white panelingÆÆ| Exterior view of building in its context | Hall with skylight and artwork | Staircase in the hall

Zaans Medisch Centrum

Architect

Mecanoo

Client

Zaans Medisch Centrum and Vitaal Zorg Vast

Zaandam, the Netherlands

134

GENERAL HOSPITALS

Completion

2017

Floor area

39,000 m2

Capacity

137 beds

The Zaans Medisch Centrum professes to be the first lean hospital in Europe. Prevention of waste at all levels – money, time, resources – was key. Relatively small in scale, the Centrum’s height hardly exceeds that of the trees in its vicinity. These create a soft transition to the city of Zaandam. A so-called ‘care boulevard’ contributes to the seamless integration of the building into its urban setting. This ‘boulevard’ – a clearly marked pedestrian route that leads to the hospital’s entrance – contains various shops, forming a functional link between hospital and city. How lean design can be combined with the principles of a healing environment inside

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8

6 6

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11 1

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6

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13 11

1 Street

8 Services

2 Rooftop garden

9 Visitor elevators

3 Oral surgery

10 Patient elevators

4 Pain clinic

11 Back-of-house

5 Knowledge center

12 Balconies

6 Clinic

13 Outpatient clinic

7 Operating room

14 Intensive care

the building was tested with life size mock-ups of 15 departments. Zaans Medisch Centrum distinguishes five patient flows: acute, elective, outpatient, diagnostics (supporting primary care) and the clinic. The ground floor as well as the first and second floors are reserved for the outpatient departments and the hot floor: an operating theater with eight rooms, the intensive care unit, cardiac care, the diagnostic center, a day care center, the laboratory, a pharmacy and public functions. Complementing these units, the hospital has several theme clusters organized according

Cross sections

to the ‘shop-in-shop’ principle, which results in designated areas such as the pain center, the exercise center, facilities for oncology (in cooperation with the Westfriesgasthuis in Hoorn and the Waterlandziekenhuis in Purmerend) and a cardiovascular center. The clinic is located on the fourth and the fifth floor; balconies give patients and visitors direct access to the world outside. Mecanoo combined a square building with a rectangular volume that is situated at an angle of 45 degrees; on the ground floor and the first floor they are separated by the entrance hall that

connects the square facing the city with the care boulevard. Perpendicular to this hall, a two-story interior street connects the two volumes. Skylights guarantee ample daylight. Both ends of the street have a green atrium. The lower three floors are clad in red brick that refer to the buildings in the vicinity. The third floor cantilevers slightly outward; the clinic is dressed in vertical panels in a light gray shade. Wooden curved lines (marking the skylights and interior balconies on the first floor) and artwork that refers to the history of the Zaan region help to give the building a friendly, neighborly appearance.

ZAANS MEDISCH CENTRUM

135

Spacious walkway on the first floor | Use of color, natural material and artwork | Waiting areas

136

GENERAL HOSPITALS

Second floor plan

1 Street 2 Outpatient clinics 3 Emergency room 4 Radiology 5 Back-of-house 6 Pre-operational screening 7 Patios 8 Care boulevard 9 Nuclear medicine 10 Oncology 11 Pain clinic 12 Knowledge center 13 Clinic First floor plan

14 Laboratory 15 Visitor elevators 16 Patient elevators

Ground floor plan

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ZAANS MEDISCH CENTRUM

137

Third floor plan

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"" Reception desk I Glass panels with artwork in the corridor I View of corridor I A sculptur­ al staircase connects the floors

138

GENERAL HOSPITALS

1 Children's department 2 Care suite 3 Dialysis 4 Rooftop garden 5 Playroom 6 Clinic 7 Balconies 8 Operating room 9 Recovery/holding 1 0 Outpatient treatment 11 Central sterilization department 12 Intensive Care Unit 13 Care boulevard 14 Visitor elevators 15 Patient elevators Fourth floor plan

13

ZAANS MEDISCH CENTRUM

139

Site plan

Longitudinal section

Hôpital RivieraChablais Rennaz, Switzerland

Architect

Groupe-6 (Denis Bouvier), GD architectes (Laurent Geninasca)

Client

Conseil d’Etablissement Hôpital Riviera-Chablais, Vaud-Valais

140

GENERAL HOSPITALS

Completion

2019

Floor area

60,000 m2

Capacity

350 beds

The location of Hôpital Riviera-Chablais near a small village at the border of two Swiss administrative regions (‘cantons’), Vaud and Valais, was a consequence of a merger between two regional hospitals, which will concentrate the medical facilities now dispersed over five sites. In a rural area, this was seen as the only option for delivering high-quality care. Since most patients as well as the staff are expected to arrive by car, the proximity to main traffic arteries was vital. In 2011, Groupe-6 and GD architectes won the design competition for the new facility. The layout of the hospital appears to reinvent the comb-like structures that were first

Floor plan inpatient ward

Glazed lower floors and entrance | View onto the Alpine surroundings | The building in its environment | Main hall | Patient ward (renderings)

introduced in the 1960s (notably in the famous Hvidovre Hospital near Copenhagen) and became popular in the 1970s. These low-rise structures lacked the awe-inspiring, overwhelming quality of the slabs and towers typical for the 1950s and 1960s. Instead, they emulated the interaction between public spaces and parceling structure of historical, organically grown cities, one of the advantages being a high degree of flexibility. Flexibility guided the decision for choosing a similar layout here, although the site lacks the urban characteristics structuralist buildings are often associated with. The hospital’s modest height of only three levels enables a seamless

transition with its surroundings. The architects, Denis Bouvier from Groupe-6, based in France, and Laurent Geninasca from Swiss GD architects, designed an introverted structure with a central spine. Instead of a basement with technical facilities, the services are placed on the roof, hidden from view by the same dark mineral stone cladding that distinguishes the top floor with the wards. Two helipads are also located on the roof. The inpatient areas are designed as four rectangular blocks, each with a spacious patio, on either side of the central spine; the spaces in between are endowed with roof gardens that enhance the pavilion-like characteristics of the wards. Many

of these are pierced by lightwells that bring daylight to the floors below. The patient rooms offer a sublime view on the Alpine surroundings. The two floors below accommodate the medical functions; a striking feature is the glass curtain wall that floods the interior of these departments with daylight, including the glazed peripheral corridors used by patients and visitors. A ramp gives access to the emergency department on the first floor and the acute care services. Outpatient departments and facilities that require constant restocking are situated on the ground floor. The hospital is remarkably compact and will be relatively easy to expand.

HÔPITAL RIVIERA-CHABLAIS

141

Longitudinal section through atria

Cross section

Reception desk | Entrance with its glazed hall and rounded corner | Main hall with ‘house-in-the-house’ and artwork suspended from the ceiling | Voids and staircase in the main corridor

Medisch Spectrum Twente Enschede, the Netherlands

142

GENERAL HOSPITALS

Architect

IAA Architecten

Client

Medisch Spectrum Twente

Completion

2016

Floor area

78,400 m2

Capacity

620 beds

The new extension of the Medisch Spectrum Twente replaces two existing facilities. Situated next to each other and connected by an 800 m long pedestrian bridge, the facilities were housed in two old hospital locations. Combined, they hosted sufficient medical specialties and treated large enough numbers of patients to qualify as a teaching hospital, in cooperation with the University Medical Center of Groningen. The MST is connected in a network with the hospital locations in Oldenzaal, Haaksbergen and Losser. The new building acts as the network’s central hub. The adjacent, defunct hospital was upgraded and now functions as a service building.

12.

13.

Ground floor plan 1 Entrance

1.

2 Entrance parking garage 4.

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3 Reception 4 Atrium

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5 Meditation space 6 Ambulance entrance 7 Emergency department 11.

8 General practice center

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9 Existing hospital 10 Women and children’s

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health center 5. 8.

11 Restaurant 12 Dialyses

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13 Opthalmology 14 Laboratory

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0 4

Harry Abels (IAA Architecten) designed a remarkably transparent and unobtrusive building that is located in the city center – a consequence of the decision to stay at the historical site and in line with the ambition to minimize the gap between the medical world and the city. It allowed Abels to use this project to contribute to an urban repair process (‘Stadtreparatur’, to use the more common German expression): the building helps to heal the urban tissue where the demolition of textile factories left so many scars. The city council supported the decision to stay in the center by making a nearby parking garage accessible from the new building via a tunnel.

The fourth floor acts as the hospital’s functional core. It contains the operating theater with ten general operating rooms, three operating rooms dedicated to heart surgery as well as two hybrid ones. Intensive Care Unit, cardio care and heart catheterization are also located here. The floors below contain the public spaces and the medical facilities that attract the largest number of patients and visitors. Patient wards occupy the upper floors. This zoning scheme resembles the three-flow model discussed in chapter ‘Zoning and Traffic System’ (p. 53), albeit that these flows have now been organized vertically. The architect combined this strategy with the theme model:

40m

clusters like mother-and-child or oncology concentrate most medical functions needed to provide proper cure and care. This results in a horizontal zoning in patient groups that completes the vertical subdivision in the wards, the hot floor and the public areas. The main entrance sits in the outer corner of the L-shaped building, where the wall lining the Koningstraat moves slightly forward as if to welcome visitors, a gesture underlined by the rounded corners and the abundant use of glass. The entrance leads to an interior square from where two spacious corridors provide access

MEDISCH SPECTRUM TWENTE

143

View toward a patient room | View from a patient room toward the hall | Waiting area on the first floor

to the spaces in the two wings. Here public functions like the reception area and a restaurant can be found.

patient rooms. Providing privacy to the patients has been a major ambition in the design of the Medisch Spectrum Twente.

The entrance square is one of the five atria that flood the building with daylight. Each atrium is the heart of one of the themed clusters. The atria offer views from the patient rooms on the upper floors to the artwork that is suspended from the glazed roofs. The main traffic arteries to the themed clusters are located on the first floor. Daylight and artworks as positive stimuli refer to some of the principles of evidence-based design, but more important is the use of only single

The clear distinction in functional zones and the themed clusters facilitate wayfinding. Art helps patients and visitors to stay aware of where exactly they are. A dynamic, continuously changing digital photo on a big screen, located in the passageway to the parking garage and designed by Geert Mul, is one of the building’s highlights; Merijn Bolink, Maria Roosen, Karin van Dam, Hans van Bentem and Ram Katzir created the artwork in the atria.

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GENERAL HOSPITALS

Second floor plan 1 Auditorium 2 Foyer/meeting rooms

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3 Vascular surgery 4 Pulmonary medicine

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5 Cardiology/thoracic surgery 6 Neurology

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7 Gastro-enterology 8 Oncological center 3.

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First floor plan 1 Dermatology

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2 Orthopedics 8. 10.

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3 Rehabilitation

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4 Surgery/plastic surgery 1.

5 Oral surgery

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6 Outpatient treatment 2.

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8 Radiology 11.

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MEDISCH SPECTRUM TWENTE

145

Fourth floor plan 1 Paramedical area 2 Open psychiatric ward 3 Private psychiatric ward 4 Secure psychiatric ward 5 Psychiatric treatment room 6 Technical space 7 Gym exercise room for patients 8 Nursing ward

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Third floor plan 1 Hybrid operating room 2 Cardiac catheterization 9.

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3 Thorax ICU

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4 Thorax operating room 5 Operating room 6 Holding 10.

7 Cardiac care unit

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146

GENERAL HOSPITALS

40m

Sixth floor plan

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MEDISCH SPECTRUM TWENTE

147

Fourth floor plan

Third floor plan

Exterior view | Entrance | Oval volume with the patient wards | Access to emergency department

Rey Juan Carlos Hospital

Architect

Rafael de La-Hoz

Client

City of Madrid, Public Health Service

Madrid, Spain

148

GENERAL HOSPITALS

Completion

2012

Floor area

94,705 m2

Capacity

260 beds

The Rey Juan Carlos Hospital adds a striking note to the Madrid suburb of Móstoles: if it doesn’t look like a healthcare facility, this may be because, to some, it doesn’t look like a building at all – not in the traditional way at least. Rectangular openings for doors and windows, for instance, a common aspect of almost all buildings, have been banned. Instead, Rafael de La-Hoz Architects designed an abstract composition of a rectangular box that is covered by a screen of narrow horizontal bands in a dark color, which protects the interior against inclement sunlight. This structure is topped by two oval towers clad in bright, shining material that forms

Longitudinal section

diamond-shaped panels, producing a conspicuous contrast with the horizontality of the box below. This sculptural icon does not correspond with its surroundings in any way, neither in its scale nor in its visual characteristics nor in the materials that were chosen. It is a completely introverted complex, a world in itself – and that is precisely what the designers had in mind. Remarkable though this building may be, it is not without precedent. It is a radical reinterpretation of the very well-known hospital type that is often referred to as a ‘matchbox on a muffin’, better known under its German name ‘Breitfuß’, namely a box at the bottom housing the treat-

ment areas, the outpatient area and the emergency department, and separate volumes on top of it accommodating the inpatients. The threestoried box of the Rey Juan Carlos Hospital is made up of three parallel zones divided by two spacious patios: the inpatient wing faces the street and is connected with the main entrance, the central zone is reserved for the treatment areas, while the third zone, separated from the hot floor in the central zone by a calm and serene patio, accommodates the emergency department. The patios are lit by circular skylights, the consultancy rooms of the outpatient department face the street, shielded against direct sunlight

by the impressive screen that envelops the entire low-rise box. The two inpatient wards on top of it are organized around large open patios with gardens. Each tower has five floors of patient rooms, which can be reached via galleries that allow a view of the garden. The rooms face outside; each of the shining panels that clad the walls is pierced by a circular window that provides vistas of the surrounding suburban settlement while special care has been taken to protect the rooms against direct sunlight.

REY JUAN CARLOS HOSPITAL

149

Patient room | Patient bathroom | Main hall | Patio with tilted roof | Entrance

150

GENERAL HOSPITALS

First floor plan

WARDS

ICU DIAGNOSIS RADIOLOGY

SURGERY EMERGENCY LOGISTICS

OUTPATIENT ADMINISTRATION REHAB

Diagram showing functions

PARKING

Ground floor plan

REY JUAN CARLOS HOSPITAL

151

Longitudinal section

The hospital’s arcadian setting | Exterior with main entrance at night | Exterior with connecting bridges

Meander Medisch Centrum

Architect

Atelier PRO architekten (Hans van Beek)

Client

Meander Medisch Centrum

Completion

2013

Floor area

112,000 m2

Capacity

600 beds

Amersfoort, the Netherlands

152

GENERAL HOSPITALS

This impressive new hospital replaces two predecessors with vastly different cultures, one having been founded by Catholic devotees, the other by their Protestant counterparts. One objective of the new institution was to foster a community spirit among its members of staff. When the merger of the two previous hospitals was contemplated, Dutch healthcare architecture was still dominated by a handful of specialized firms that produced large quantities of indistinct buildings which strictly followed the rules laid out by the national planning agency. Convinced that Amersfoort needed something better than that, the hospital board invited Atelier PRO, an

1 Main entrance 2 Entrance from parking garage 3 Information desk 4 Ambulance access 5 Emergencies 6 Central street ‘Avenue’ 7 Public space ‘Brink’ 8 Public space ‘Foyer’ 9 Wintergarden ‘Oranjerie’

Site and ground floor plan

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The wintergarden ‘Oranjerie’ | Wedge-shaped lounge and single-patient room | Avenue with reception

The wards separate the central spine from the hot floor, a solution that results in a rather large distance between the hot floor and the outpatient departments. While the design of the hot floor is determined by the medical processes, the other parts refer to building types outside the realm of medicine: the wards were conceived of as a luxury hotel, while the outpatient department took inspiration from office spaces. Emphasizing a private atmosphere, single-patient rooms are the norm in the new hospital, the first general hospital in the Netherlands to completely abandon the classical multiple bedroom. Sliding doors connect the rooms to a so-called living

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room, a wedge-shaped lounge that offers a view either to the greenery outside or to the Avenue. Each living room has a coffee corner and a computer station. The fluent transition from the private realm of the rooms via the semi-private environment of the lounge to the public domain of generous circulation spaces is expected to stimulate recovering patients to gradually expand their radius. Wayfinding is greatly facilitated by the simple overall layout and the visual connections with the outside. Color further enhances the navigation through the building. Illuminated green panels signal the hospital reception desks, for instance, and the entries

of the clinics are marked by signal colors and waiting areas by a green wall. Color is also used to enliven the interior: the overall effect is one of serenity and calm. Warm, natural materials such as wood have been used in the public areas as well as in the patient rooms, and thanks to the abundance of glass there is plenty of daylight. However, the lighting concept of the hospital prevents the effect of a flood-lit factory, accepting low-light conditions where this contributes to a pleasant atmosphere. Wishing to avoid an institutional feel, the architects decided to design all the furniture themselves – some 3,000 pieces.

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4 Void above wintergarden ‘Oranjerie’ 5 Auditorium 6 Restaurant 7 ROC (regional education center)

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emergency area, laboratories

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First floor plan

MEANDER MEDISCH CENTRUM

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Plan of ICU

Double skin with view on the surroundings | General view of the building | Glazed corridor with palmtrees | View of the central spine

Cleveland Clinic Abu Dhabi

Architect

HDR

Client

Mubadala Development Company

Abu Dhabi, United Arab Emirates

156

GENERAL HOSPITALS

Completion

2015

Floor area

409,234 m2

Capacity

364 beds (expandable to 490)

Traditionally, the residents of the United Arab Emirates (UAE) used to travel to Europe and the United States for state-of-the-art medical treatment and care, but in recent years, the government has been carefully investing in new facilities and technology, partnering with leading international medical providers to bring specialist knowledge and expertise to the country. With the opening in March 2015 of Cleveland Clinic Abu Dhabi, residents of the UAE can make use of the sophisticated care services available at the first replication of US-based Cleveland Clinic outside of North America. Cleveland Clinic’s network includes facilities in Ohio, Las Vegas, Florida and Toronto.

Plan of typical patient floor

Cleveland Clinic Abu Dhabi, a 364-bed facility, is built as a composition of six rectangular blocks and slabs, constituting the ‘Gallery’ (a public space), a diagnostics and treatment section, an intensive care unit, the administrative wing and a patient tower. The outpatient clinics comprise 243 examination rooms. The uppermost slab, clad in a double-glazed curtain wall, contains the inpatient acute care wards (the ICU is being housed in a cantilevered wing beneath). The building can be seen as a contemporary interpretation of the 1960s matchbox-on-a-muffin or Breitfuß type, the subdivision of the lower levels representing the transition to patient-centered care in dedi-

cated volumes, and the relatively modest scale of the slab with patient wards expressing the decreasing number of days inpatients spend in hospital. Wayfinding is based on the distinctive function of the slabs and boxes and the separation of flows, and facilitated by the views to the outside.

of evidence-based design, which inspired the project at all levels. A retail gallery offers distractions of patients and visitors. With over 20 floors, Cleveland Clinic Abu Dhabi adds an architectural landmark in the center of Al Maryah Island, the city’s new business district, and symbolizes the very best that hospitalbased medicine has to offer.

Arranged around a central water feature, sitting on an island and overlooking the Arabian Gulf, water is a principal theme of the hospital. Landscaping, roof gardens and greenery inside the building provide direct visual contact with nature. These qualities reflect the principles

CLEVELAND CLINIC ABU DHABI

157

Children’s Hospitals

Children are a special category of patients, ranging from neonates to young adults, clustered in five age groups, each with its own distinctive characteristics and needs: neonates (0–28 days), infants (28 days to 1 year old), toddlers (1–3 years old), early-school children and preadolescents (3–12 years old), adolescents and young adults (12–18 years old). While general hospitals usually dedicate a (relatively small) part of their buildings to children’s healthcare, with child-friendly design an afterthought, specialized children’s hospitals have emerged as a type of their own. They are totally focused on ameliorating the pain, fear and distress caused by disease and medical interventions. In addition, they typically provide opportunities for play and often also facilities for schooling. Especially in the United States, where child obesity is a major issue, facilities for children to play outside have become a trend in new children’s hospitals. Landscaped playgrounds, for instance, invite them to run around instead of spending too much time watching television or gaming. Medical equipment augments children’s fear and distress. The design of facilities should therefore focus on normal, child-friendly spaces, with medical equipment concealed or stowed away as much as possible. Since children appear to be more sensitive to the qualities of the environment than adults, the healing environment concept is particularly important. Not only are color, natural light, reduction of sound levels and greenery generously used in many facilities, often there are positive references to the children’s life outside the hospital, for instance to school architecture, theme parks, even toy stores. Most important is enabling close contact with the parents, who ideally should be offered the opportunity to stay overnight either in the immediate vicinity (in Ronald McDonald houses, for instance), or in their child’s patient room. The most important changes can therefore be found in the patient room. Over the years, it has grown larger, more private, and, increasingly, family-centered, with up to three distinct zones: the patient’s, the parents’ and the caregivers’.

7 1

2

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Ground floor plan 1 Library 4

2 Dining 3 Administration 4 Retail space

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5 Roof 6 Learning center

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7 Data center 0

Nemours Children’s Hospital Orlando, Florida, USA

3

10

Architect

20m

Stanley Beaman & Sears with Perkins + Will (Associate Architects)

Client

Nemours Children’s Hospital

160

CHILDREN’S HOSPITALS

Completion

2012

Floor area

58,527 m2

Capacity

95 beds

Seen from outside, the most intriguing feature of the Nemours Children’s Hospital is probably the cheerful effect of the inpatient rooms at night. Children are allowed to choose the color of the light in their temporary lodging, transforming this part of the building into a light spectacle that changes almost daily. It is the outward manifestation of an idea that marks contemporary healthcare architecture: patients need to feel empowered. This is a building for children who, no matter how young they are, should be taken seriously. The color tableau adds an enjoyable note in already pleasurable surroundings. With its agreeable climate, lots of sunshine and high

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13 12

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First floor plan 8 Surgery

11 13 12

9 PACU 10 Pre-OP space 11 Recovery 12 Commons

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13 Void 14 Outpatient clinics 15 Roof garden

Façade detail with shades | The building in its surroundings | Roof garden | Children playing in the roof garden

temperatures, Florida doesn’t need much else to qualify as the prime leisure state of America, although the numerous theme parks in the state are a welcome addition. Set in a wooded area near Orlando, with the silhouettes of several tourist attractions dotting the horizon, Nemours Children’s Hospital adds a pleasant landmark to this scenery. The architects took care not to design Nemours as another theme park: an atmosphere of serenity and calm pervades the interior.

land far away from the hassle of city life. It profits from close connections to the medical services provided there. Its immediate surroundings offered little the architecture could relate to – except for the natural scenery. Even so, the building does refer, however abstractly, to the French city of Nemours – that is where the founder of the client foundation came from. Like its namesake, it is a dense, urban complex set in a landscape marked by water, in this case a multitude of small lakes.

Nemours is built on the campus of Lake Nona Medical City on a site that used to be agricultural

The institution acts as an intermediary between technology-driven medicine and the preventive

and supportive properties of the environment, combining the best of two worlds. Following initial studies by Roger Ulrich in the 1980s, the guiding design principles were the positive effect of sunlight and the focus on the surroundings of the building. Views and natural light were thus primary concerns. Working with an extensive team of experts, among them AECOM landscape designers, the architects wanted to create a hospital in a garden. Nemours Children’s Hospital boasts two roof gardens. A discovery garden is dedicated to the senses: there are fragrant plants that stimulate smelling and soundscapes that speak to the ears. Whereas this garden is

NEMOURS CHILDREN’S HOSPITAL

161

Typical waiting area | Green elevator lobby | Waiting area | Play area | Patient room

reserved for the children who are treated in the adjacent department, the second rooftop garden is open to everybody, offering children and their companions opportunities to focus on rehabilitation, including an obstacle course and walking paths. At Nemours, children with chronic disorders are at home as well as children with complex diagnoses or life-threatening diseases. It has 95 beds and 76 consultancy rooms; additional space can accommodate 32 beds and 24 consultancy rooms on top of that. Instead of opting for a generic outpatient department with shared

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CHILDREN’S HOSPITALS

consultancy spaces, each medical specialization has its own rooms. Guiding principle of the hospital’s organizational concept was the decision to locate the clinics for inpatients at the same level as the outpatient departments. The selection of distinct design features for each level helps children and their parents to establish a more intimate relationship with the facilities they use as well as with the nursing staff working there. Since children’s hospitals are as much about parents as they are about children, the hospital board embraced the principle of familycentered care, including sleeping facilities for two persons in each of the single bedrooms.

The layout comprised six levels on a raised ground floor with delivery and services underneath. Careful landscape design including a green mound disguises the fact that the entrance is on the first floor, hiding the services and the delivery area underneath. Also on the first floor are the administration and a learning center. Surgery and a generic outpatient department occupy the floor above. Wayfinding is facilitated by giving each floor its own color, texture, imagery and artwork. Landmarks, among them a saltwater tank donated and maintained by Sea World, the well-known nearby theme park, help patients and visitors to find their way.

Main lobby | Main entrance from entry court at night

NEMOURS CHILDREN’S HOSPITAL

163

10

9

Section 1 Lower level: Children’s day surgery 2 Ground floor: Main lobby, emergencies 3 First floor: NICU

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4 Second floor: Outpatient cancer center,

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5 Third floor: Oncology, cardiac department,

roof garden family lounge 6

6 Fourth floor: PICU, family lounge 7 Fifth floor: Medical department infants

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Clinical

and toddlers, surgery, family lounge 8 Sixth floor: Medical department school

Clinical support

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age children, family lounge 9 Seventh floor: Orthopedics, neurology,

Amenity

3

rehabilitation, family lounge 10 Eighth floor: Reserve space, family lounge

Office 2

Building structure 1

Garden

Exterior view | Lobby with reception | Elevator lobby | Family interaction room | Gallery corridor

Randall Children’s Hospital at Legacy Emanuel Portland, Oregon, USA

Architect

ZGF Architects

Client

Legacy Health

Completion

2012

Floor area

31,030 m2

Capacity

165 beds

The use of art is key to understanding the Randall Children’s Hospital in Portland. Formerly dispersed across the city in small units, the pediatric services of the Legacy Emanuel Medical Center are now concentrated in one single, nine-story building. ZGF Architects LLP (Zimmer Gunsul Frasca) was involved from the earliest stages of the project, which allowed them to actively participate in the formulation of design criteria. Organizing workshops with the hospital board and the prospective users, ZGF prepared a set of ‘guiding principles’ based on ten values, the overarching goal being to create an inspiring,

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CHILDREN’S HOSPITALS

Ground floor plan

fascinating, distracting and comfortable environment for people of all ages. One of the guiding principles was the use of art. Not only is art employed as a means to create attractive places, it also provides destinations for visitors and patients, as the artwork is an integral element in the wayfinding system. Since there is ample scientific data proving that children have a strong affinity for images from the natural world, imagery of the Oregon and the southwest Washington landscapes became a primary design driver, connecting the natural habitat of the region with the interior of the new building. Each floor is endowed with a specific animal that

0'0 8' 16' 5

32' 10

64' 20m

provides identity and facilitates orientation: dears, foxes, bears, hummingbirds, etc. These are etched in customized art glass and shown in the nurse stations at the eye-level of a toddler. The abundant use of color also refers to regional landscapes; these, too, are used to identify specific parts of the building: a soft Oregon Coast color palette indicates the neonatal intensive care unit, a rich palette inspired by the Cascade Range is used in the outpatient oncology floor while the desert palette of bright oranges and reds designates the emergency and day surgery department. Used in ceilings, floors, doors and

headwalls, bamboo adds a natural color background to this thematic diversity. The artist Fernanda D’Agostino created sculptural, coneshaped elements of glass for the terrace garden on the third floor; covered with a colored lens, they also act as skylights for the neonatal intensive care unit underneath. Another key design objective was the use of soft, curved shapes, which give the hospital an organic feel. Glass panels, pergola structures, plants and paving material were chosen to create a restorative environment. The terrace garden offers places for play, for social interaction and for contemplation.

RANDALL CHILDREN’S HOSPITAL AT LEGACY EMANUEL

165

Lobby in children’s day surgery | Nurse station | Views of patient rooms

The philosophy that pervades the building is the now generally accepted principle of family-centered care. Inpatients and their families occupy the top floors. Randall Children’s Hospital has single bedrooms only; they are furnished with hotel quality elements, among them a double sleeping sofa for parents. Two-storied, glassenclosed family lounges on each patient floor provide patients and their families with a place for respite and relaxation away from patient rooms. The building also boasts a family wellness center and a small movie theater with 15 seats. Distractions for patients, which can also be enjoyed by their families, are offered in an

166

CHILDREN’S HOSPITALS

activity room, playrooms and a teen lounge with computers for gaming. With 165 inpatient beds Randall Children’s Hospital is a medium-sized institution adjacent to an existing hospital, which shares some of its facilities. The day surgery unit, for instance, is connected with the operating theater in the other building. A tunnel on the basement level allows easy access. The eighth floor is laid out in anticipation of further expansion. The hospital occupies a landscaped plot with parking and greenery areas dotted with street furniture.

Third floor plan

0'

8' 16'

32'

64'

Second floor plan

0'

8' 16'

32'

64'

First floor plan

0' 0

8' 16' 5

32' 10

64' 20m

0'

8' 16'

32'

64'

RANDALL CHILDREN’S HOSPITAL AT LEGACY EMANUEL

167

? ? ??

398 POLI B LOED functiek amer J 0.09 16 m²

POLI B LOED afnamecab. J 0.15 7 m²

FO + FYSIO behandelk amer J 0.33 15 m²

V ERKEERSRUIMT E gang J 0.23V 9 m²

FYSIO individuele behandelcab. J 0.67 16 m²

J KZ ( SO) balieopp. J 0.103B 14 m²

5640 J KZ ( SO) J KZ ( SO) voorruimte toiletten pers. voorruimte toilet pers. J 0.20 J 0.25 4 m² 2 m²

T ECHNIEK schacht J 0.S01 6 m²

J 0.20A

J 0.22A

J 0.20B

J 0.25A

J 0.22B

J 0.22C

J 0.31A

FO + FYSIO longfunctie J 0.37 23 m²

J 0.27B

J 0.31B

J 0.31C

J KZ ( SO) MIV A toilet bez . J 0.29 4 m²

J 0.31D

V ERKEERSRUIMT E gang J 0.39A 5 m²

RA DIOLOGIE schak elruimte J 0.53 12 m²

RA DIOLOGIE buck yk amer J 0.45 25 m²

J KZ ( SO) voorruimte toiletten bez . heren J 0.27 9 m²

J 0.27A

RA DIOLOGIE schak elruimte J 0.45B 4 m²

RA DIOLOGIE k leedruimte pat. J 0.45A 2 m²

FO + FYSIO audio, if cardio en k nf lab. J 0.39 12 m²

J KZ ( SO) voorruimte toiletten pers. J 0.22 6 m²

1345

1400

HEMA T O./ ONCO./ A NEST HESIO. HEMA T O./ ONCO./ A NEST HESIO. HEMA T O./ ONCO./ A NEST HESIO. HEMA T O./ ONCO./ A NEST HESIO. back office back office back office back office H0.17 H0.17A H0.19 H0.19A 6 m² 6 m² 7 m² 7 m²

A OH extra tov B B ipv onderst. ruimten H0.25 19 m²

T ECHNIEK schacht J 0.S03 2 m²

FYSIO MIV A toilet J 0.77 4 m²

FYSIO opslag J 0.81A 4 m²

V ERKEERSRUIMT E gang J 0.111V 18 m²

FYSIO toilet J 0.83A 1 m²

HEMA T O./ ONCO./ A NEST HESIO. toilet pers. H0.11 6 m²

H0.11A

FYSIO wachtruimte J 0.115W 33 m²

A OH S.O. k amer H0.39 27 m²

A OH spreek k amer apoth. H0.06 10 m² A OH S.O. k amer H0.10 20 m²

V ERKEERSRUIMT E gang J 0.115V A 2 m²

RA DIOLOGIE werk ruimte laborant J 0.55 17 m²

A OH S.O. k amer H0.12 20 m²

A OH S.O. k amer H0.14 20 m²

A OH S.O. k amer H0.18 20 m²

A OH S.O. k amer H0.16 20 m²

J KZ ( SO) spoelruimte log. J 0.46 10 m²

FYSIO oefenz aal sport en spel J 0.95 208 m²

J KZ ( SO) wachtruimte J 0.108W.1 23 m²

J KZ ( SO) S.O. k amer J 0.38 16 m²

J KZ ( SO) balieopp. J 0.40 12 m²

J 0.40A

J KZ ( SO) S.O. k amer J 0.42 15 m²

FYSIO opslag J 0.95A 14 m²

V ERKEERSRUIMT E lift J 0.L25 8 m²

V ERKEERSRUIMT E gang H0.100V 181 m²

V T _ PL02: belasting/ gewicht < 400k g

A NEST HESIO. wachtruimte H0.100W 24 m²

FYSIO individuele behandelcab. H0.26 19 m²

FYSIO individuele behandelcab. H0.28 19 m²

FYSIO individuele behandelcab. H0.30 19 m²

DA GCENT RUM 1 receptie/ balie H0.51 17 m²

FYSIO S.O. k amer H0.32 19 m²

FYSIO S.O. k amer H0.34 19 m²

H0.54A

DA GCENT RUM 1 wachtruimte 2 H0.50 12 m²

7300

V ERKEERSRUIMT E gang J 0.118V 87 m²

J KZ werk k ast J 0.106 4 m²

J KZ ( SO) S.O. k amer J 0.82 18 m²

J KZ ( SO) S.O. k amer J 0.78 18 m²

J KZ ( SO) S.O. k amer J 0.54 16 m²

J KZ ( SO) opslag app. en speelgoed J 0.86 7 m²

900 600

650 gynaecologie S.O. k amer J 0.128 21 m²

J KZ ( SO) MIV A toilet bez . J 0.100A 4 m²

gynaecologie verk eersruimte J 0.166V 38 m²

gynaecologie vergaderz aal J 0.170A 7 m²

V ERKEERSRUIMT E gang J 0.114V 75 m²

gynaecologie S.O. k amer J 0.130 21 m²

gynaecologie toilet bez . J 0.160A 1 m² gynaecologie toilet bez . J 0.160B 1 m²

gynaecologie voorr. toiletten bez . J 0.160 7 m²

gynaecologie flex. werk plek J 0.172 6 m²

J KZ ( SO) S.O. k amer J 0.74 18 m²

J KZ ( SO) S.O. k amer J 0.80 18 m²

DA GCENT RUM 1 multifunct. overlegr./ k offier. H0.65 26 m² DA GCENT RUM 1 werk k ast H0.67 3 m²

T ECHNIEK schacht H0.S03 4 m²

DA GCENT RUM 1 opslag steriel H0.71 12 m²

J KZ ( SO) S.O. k amer J 0.102 18 m²

J KZ ( SO) S.O. k amer J 0.110 16 m²

J KZ back office J 0.48H 9 m²

gynaecologie ECHO H0.48 20 m²

gynaecologie back office J 0.174 64 m²

DA GCENT RUM 1 MIV A toilet pat. H0.73A 4 m² DA GCENT RUM 1 1p. verpleging H0.73 26 m²

V ERKEERSRUIMT E gang H0.104V 23 m² DA GCENT RUM 1 MIV A toilet pat. H0.93A 5 m²

T ECHNIEK E- k ast H0.E2 3 m²

DA GCENT RUM 1 pantry H0.68 9 m²

DA GCENT RUM 1 teampost H0.84 30 m²

DA GCENT RUM 1 1p. verpleging H0.93 23 m²

DA GCENT RUM 1 MIV A toilet pat. H0.91 4 m²

V ERKEERSRUIMT E gang H0.110V 106 m²

DA GCENT RUM 1 MIV A toilet pat. H0.74A 4 m²

DA GCENT RUM 1 flex. werk plek H0.70B 6 m²

DA GCENT RUM 1 MIV A toilet pat. H0.88A 4 m²

DA GCENT RUM 1 MIV A toilet pat. H0.82A 4 m²

DA GCENT RUM 1 MIV A toilet pat. H0.78A 4 m²

DA GCENT RUM 1 flex. werk plek H0.88B 6 m²

DA GCENT RUM 1 4p. verpleging H0.96 57 m²

2118

DA GCENT RUM 1 4p. verpleging H0.88 52 m²

DA GCENT RUM 1 4p. verpleging H0.74 52 m² FO + FYSIO k l. neurofysiologie J 0.138 26 m²

V ERKEERSRUIMT E gang H0.108V 33 m²

DA GCENT RUM 1 depotheek H0.66 29 m²

DA GCENT RUM 1 1p. verpleging H0.78 25 m²

gynaecologie S.O. k amer J 0.164 24 m²

0

Diagram showing distribution

V ERKEERSRUIMT E trappenhuis H0.T 29 13 m²

H0.62B

DA GCENT RUM 1 voorruimte toiletten H0.62 3 m²

DA GCENT RUM 1 4p. verpleging H0.70 52 m²

J KZ ( SO) S.O. k amer J 0.96 17 m²

H0.61A

H0.61B

T ECHNIEK E- k ast J 0.E8 2 m²

3221 J KZ ( SO) S.O. k amer J 0.90 17 m²

DA GCENT RUM 1 voorr. toiletten pers. H0.61 5 m²

FYSIO S.O. k amer J 0.162 21 m²

1400 J KZ ( SO) S.O. k amer J 0.68 18 m²

T ECHNIEK trafo H0.E3 1 m²

gynaecologie S.O. k amer H0.46A 16 m²

gynaecologie C.T .G. H0.46C 9 m²

DA GCENT RUM 1 MIV A toilet pat. H0.70A 4 m²

J KZ ( SO) nis J 0.114V A 1 m²

J KZ ( SO) S.O. k amer J 0.64 17 m²

DA GCENT RUM 1 behandelk amer ( puncties) H0.57 20 m²

DA GCENT RUM 1 schone werk ruimte H0.62C 4 m²

DA GCENT RUM 1 spoelruimte H0.64 10 m²

V ERKEERSRUIMT E gang J 0.119V 144 m²

gynaecologie S.O. k amer J 0.158 21 m²

gynaecologie pantry J 0.168 23 m²

T ECHNIEK SER- ruimte J 0.P2 8 m²

J KZ ( GV ) wachtruimte J 0.116W 82 m²

J KZ ( SO) S.O. k amer J 0.60 18 m²

H0.62A

gynaecologie S.O. k amer H0.46B 16 m²

384

J KZ ( SO) overleg J 0.114A 3 m²

J KZ ( SO) S.O. k amer J 0.58 18 m²

gynaecologie ECHO H0.42 21 m²

gynaecologie opslag steriel H0.40B 6 m²

gynaecologie S.O. k amer ( Z .B .K.) H0.40A 6 m²

gynaecologie vergaderz aal J 0.170 7 m²

J KZ ( SO) opslag medimath J 0.94 10 m²

FO + FYSIO audiometrie J 0.88 21 m²

J KZ back office J 0.76 15 m²

J KZ back office J 0.48F 5 m²

J KZ ( SO) S.O. k amer J 0.56 18 m²

gynaecologie S.O. k amer ( Z .B .K.) H0.40 15 m²

200

gynaecologie opslag J 0.156 4 m²

gynaecologie toilet pers. J 0.154 3 m²

gynaecologie S.O. k amer J 0.126 21 m²

J KZ ( SO) balieopp. J 0.116B 22 m²

J KZ back office J 0.48D 48 m²

J KZ back office J 0.48G 8 m²

1500

gynaecologie S.O. k amer ( Z .B .K.) H0.36A 6 m²

3500

V ERKEERSRUIMT E gang J 0.121V 8 m²

gynaecologie verk eersruimte J 0.166V 38 m²

V T _ PL02: belasting/ gewicht < 400k g

J KZ ( SO) grote spreek k amer J 0.100 24 m²

J KZ ( SO) k olfk amer J 0.84 4 m²

DA GCENT RUM 1 2- bedsk amer hemaferese H0.55 44 m² DA GCENT RUM 1 spreek k amer/ flexplek H0.56 24 m²

H0.58B

600

J KZ ( SO) overleg J 0.112A 2 m²

J KZ ( SO) S.O. k amer J 0.72 15 m²

J KZ ( SO) S.O. k amer J 0.66 16 m²

V ERKEERSRUIMT E gang J 0.110V .2 14 m²

1800

gynaecologie spreek uurafronding 2 J 0.152 10 m²

V ERKEERSRUIMT E gang H0.38V 28 m²

V ERKEERSRUIMT E gang J 0.112V 43 m²

J KZ ( SO) S.O. k amer J 0.52 15 m²

gynaecologie spoelruimte J 0.150 7 m²

gynaecologie S.O. k amer J 0.124 20 m²

V ERKEERSRUIMT E gang J 0.110V .1 26 m²

J KZ ( SO) S.O. k amer J 0.50 15 m²

gynaecologie S.O. k amer J 0.146 20 m²

gynaecologie S.O. k amer J 0.144 21 m²

gynaecologie S.O. k amer J 0.142 21 m²

V ERKEERSRUIMT E gang J 0.116V 64 m²

V ERKEERSRUIMT E gang H0.106V 16 m²

DA GCENT RUM 1 opslag linnen H0.60 4 m²

gynaecologie ECHO H0.44 20 m²

125

J KZ ( SO) S.O. k amer J 0.70 18 m²

1805

J KZ opnamebureau J 0.108 8 m²

J KZ back office J 0.48E 5 m²

gynaecologie spreek uurafronding 1 J 0.148 15 m²

gynaecologie S.O. k amer J 0.122 20 m²

J KZ ( SO) balieopp. J 0.62 19 m²

T ECHNIEK schacht J 0.S02 6 m²

T ECHNIEK E- k ast J 0.E4 2 m²

H0.58A

4070

721 J KZ ( SO) KNO S.O. k amer J 0.98 20 m²

J KZ ( SO) KNO S.O. k amer J 0.92 20 m²

V ERKEERSRUIMT E trappenhuis J 0.T 23 14 m²

gynaecologie S.O. k amer ( Z .B .K.) H0.36 15 m²

DA GCENT RUM 1 behandelk amer ( puncties) H0.53 21 m²

V ERKEERSRUIMT E gang H0.102V 12 m²

DA GCENT RUM 1 voorruimte toiletten H0.58 3 m²

gynaecologie toilet pat. H0.42A 2 m²

J KZ opnamebureau J 0.104 13 m²

J KZ back office J 0.48B 6 m²

H0.54B

A NEST HESIO. voorruimte toiletten H0.54 3 m²

V T _ PL02: belasting/ gewicht < 400k g

J KZ back office J 0.48A 6 m²

A OH voorlichtingsruimte H0.45 6 m²

V T _ PL02: belasting/ gewicht < 400k g

A NEST HESIO. raadpleegplek H0.30A 9 m²

V ERKEERSRUIMT E gang J 0.117V 133 m²

J KZ ( SO) wachtruimte J 0.108W.2 23 m² V ERKEERSRUIMT E trap J 0.T 24 14 m²

J KZ back office J 0.48C 50 m²

A OH S.O. k amer H0.41 27 m²

DA GCENT RUM 1 wachtruimte H0.106W 20 m²

ONCOLOGIE wachtruimte H0.104W 27 m²

HEMA T OLOGIE wachtruimte H0.102W 27 m²

DA GCENT RUM 1 MIV A toilet pat. H0.52 3 m²

J KZ back office J 0.48 24 m²

A OH S.O. k amer ( Z .B .K.) H0.24 20 m²

HEMA T OLOGIE/ ONCOLOGIE receptie/ balie H0.43 17 m²

J KZ afsprak enbureau J 0.44 18 m²

J KZ ( GV ) wachtruimte J 0.106W 14 m²

V ERKEERSRUIMT E gang J 0.106V 148 m²

A OH S.O. k amer H0.22 20 m²

A NEST HESIO. receptie/ balie H0.08 14 m²

FYSIO ntb J 0.97 3 m²

2550

J 0.40B

A OH S.O. k amer H0.20 20 m²

V ERKEERSRUIMT E lift J 0.L24 8 m²

449

J KZ back office J 0.40C 2 m²

A OH S.O. k amer H0.37 27 m²

HEMA T O./ ONCO./ A NEST HESIO. back office H0.101V 41 m²

FYSIO werk r. ( unith.) H0.04 10 m²

RA DIOLOGIE receptie/ balie J 0.49 12 m²

V ERKEERSRUIMT E gang H0.105V 54 m²

V ERKEERSRUIMT E trappenhuis H0.T 28 14 m²

T ECHNIEK E- k ast H0.E1 2 m²

FYSIO multifunct. ruimte J 0.91 28 m²

FYSIO k leedruimte J 0.83 20 m²

RA DIOLOGIE echografiek amer J 0.61 15 m²

A OH S.O. k amer H0.35 27 m²

T ECHNIEK SER- ruimte H0.P1 10 m²

T ECHNIEK schacht H0.S01 5 m²

H0.11B FYSIO garderobe H0.02 10 m²

J 0.83B

J KZ ( SO) toilet J 0.28A 1 m²

J KZ ( SO) S.O. k amer ( echo) J 0.36 17 m²

FYSIO oefenz aal fitness J 0.85 81 m²

ST ILT ECENT RUM stiltecentrum H0.01 55 m²

RA DIOLOGIE k leedruimte pat. J 0.61A 2 m²

J KZ ( SO) S.O. k amer J 0.34 16 m²

J KZ ( SO) S.O. k amer J 0.32 16 m²

J KZ ( GV ) toilet bez . J 0.65A 3 m²

V ERKEERSRUIMT E gang J 0.115V 103 m²

FYSIO toilet J 0.79B 1 m²

RA DIOLOGIE toilet pat. J 0.59B 2 m²

V ERKEERSRUIMT E gang J 0.47V 32 m²

FO + FYSIO longfunctie J 0.41 28 m²

J KZ ( SO) spoelruimte J 0.28 9 m²

J KZ ( SO) nis J 0.104V A 1 m²

RA DIOLOGIE doorlichtingsk amer J 0.59 28 m²

RA DIOLOGIE k leedruimte pat. J 0.59A 2 m²

J KZ ( SO) voorruimte toiletten bez . dames J 0.31 9 m²

V ERKEERSRUIMT E gang J 0.104V 46 m²

J KZ ( SO) S.O. k amer J 0.26 16 m²

A OH S.O. k amer H0.33 27 m²

A OH S.O. k amer H0.27 20 m²

J 0.79A

FYSIO individuele behandelcab. J 0.75 16 m²

FYSIO opslag oefenz aal J 0.81 20 m²

J 0.31E

J KZ ( SO) S.O. k amer J 0.24 17 m²

J KZ back office J 0.16 116 m²

HEMA T O./ ONCO./ A NEST HESIO. back office H0.15 167 m²

150

J KZ ( GV ) toilet bez . J 0.65 3 m²

J KZ ( GV ) wachtruimte J 0.105W 5 m²

J KZ ( SO) S.O. k amer J 0.14A 16 m²

FYSIO k leedruimte J 0.79 19 m²

V ERKEERSRUIMT E gang J 0.105V 150 m²

V ERKEERSRUIMT E gang J 0.103V 46 m²

V ERKEERSRUIMT E trappenhuis J 0.T 22 14 m²

A OH S.O. k amer H0.31 22 m²

A OH S.O. k amer H0.29 21 m²

V ERKEERSRUIMT E lift J 0.L27 10 m²

V ERKEERSRUIMT E gang J 0.113V 14 m²

V ERKEERSRUIMT E gang J 0.107V 50 m²

J KZ toilet J 0.18A 2 m²

V ERKEERSRUIMT E lift J 0.L26 10 m²

V ERKEERSRUIMT E gang J 0.109V 38 m² T ECHNIEK trafo J 0.E3 1 m²

V ERKEERSRUIMT E wachtruimte J 0.103W 23 m²

J KZ ( SO) S.O. k amer J 0.14 17 m²

J KZ toilet J 0.18 2 m²

FYSIO individuele behandelcab. J 0.73 15 m²

650

650 FYSIO individuele behandelcab. J 0.71 16 m²

FYSIO individuele behandelcab. J 0.69 16 m²

FO + FYSIO behandelk amer J 0.35 15 m²

POLI B LOED receptie/ balie J 0.23 12 m²

1155

POLI B LOED afnamecab. J 0.17 8 m²

J KZ back office J 0.12 12 m²

FO + FYSIO berging J 0.51 10 m²

FO + FYSIO oefenz aal fysio k inderen J 0.57 35 m²

J KZ werk k ast J 0.07 3 m²

J KZ ( SO) nis J 0.100V A 1 m²

FO + FYSIO oefenz aal fysio k inderen J 0.43 36 m²

POLI B LOED + J KZ ( SO) opslag + werk ruimte + buiz enpost J 0.21 13 m²

J KZ ( SO) gipsk amer J 0.05 30 m² V ERKEERSRUIMT E gang J 0.100V 33 m² J KZ ( SO) S.O. k amer J 0.10 17 m²

1345

V ERKEERSRUIMT E gang J 0.101V 27 m²

V ERKEERSRUIMT E gang J 0.102V 21 m²

T ECHNIEK SER- ruimte J 0.P1 10 m²

J KZ ( SO) S.O. k amer J 0.08 16 m²

800

V T _ PL01: belasting/ gewicht max. 1500k g

650

POLI B LOED k ast poli bloed J 0.23A 2 m²

1400

J KZ receptie/ balie J 0.105B 16 m²

POLI B LOED afnamecab. J 0.11 7 m²

1400

J KZ ( SO) behandelk amer J 0.03 18 m²

650

J KZ ( SO) S.O. k amer J 0.01 16 m²

J KZ ( SO) behandelk amer J 0.04 19 m²

1400

J KZ ( SO) S.O. k amer J 0.02 19 m²

J KZ ( SO) S.O. k amer J 0.06 20 m²

2218

3236

DA GCENT RUM 1 1p. verpleging H0.82 25 m²

2

5m

Ground floor plan

of departments

Juliana Children’s Hospital The Hague, the Netherlands

168

CHILDREN’S HOSPITALS

Architect

MVSA Architects as part of the VolkerWesselsHaga consortium

Client

HagaZiekenhuis

Completion

2015

Floor area

34,500 m2

Capacity

210 beds

The Juliana Children’s Hospital (Kinderziekenhuis JKZ) is part of the HagaZiekenhuis, one of the largest hospitals in the Netherlands. Formerly accommodated in various buildings across the city, the HagaZiekenhuis now concentrates all hospital facilities at a single site. Characteristic of the architectural solution for the new facility is that it respects and strengthens the qualities of the original design: opened in 1971, K. L. Sijmons’ Leyenburg Hospital, as it was called back then, is one of the Netherlands’ most striking examples of a classical Breitfuß hospital. It is dominated by a vertical slab made of prefabricated, sculptural concrete elements that crowns a flat, horizontal

1032

1032 V ERKEERSRUIMT E loopbrug E1.120V 113 m²

MK ( UNIT B 1+ B 2) 1 persoonsk amer X L J 1.01 29 m²

MK ( UNIT B 1+ B 2) 2p. verpleging J 1.05 31 m²

MK ( UNIT B 1+ B 2) 2p. verpleging J 1.07 26 m²

MK ( UNIT B 1+ B 2) 2p. verpleging J 1.09 26 m²

MK ( UNIT B 1+ B 2) 1 persoonsk amer X L J 1.15 25 m²

MK ( UNIT B 1+ B 2) 1 persoonsk amer X L J 1.25 26 m²

MK ( UNIT B 1+ B 2) 1 persoonsk amer X L J 1.17 25 m²

DA GCENT RUM 2 spreek k amer H1.03 11 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.07A 5 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.09A 5 m²

MK ( UNIT B 1+ B 2) MIV A toilet + douche J 1.15A 5 m²

MK ( UNIT B 1+ B 2) MIV A toilet + douche J 1.17A 5 m²

MK ( UNIT B 1+ B 2) MIV A toilet + douche J 1.25A 5 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.33 17 m²

MK ( DA GV ERPL.) 4p. verpleging J 1.39 46 m²

MK ( DA GV ERPL.) 1p. verpleging J 1.57 23 m²

MK ( DA GV ERPL.) 4p. verpleging J 1.51 49 m²

MK ( DA GV ERPL.) 4p. verpleging J 1.49 46 m²

MK ( DA GV ERPL.) 1p. verpleging J 1.65 25 m²

V ERKEERSRUIMT E lift J 1.L26 10 m²

MK ( DA GV ERPL.) 1p. verpleging J 1.79 17 m²

MK ( DA GV ERPL.) 1p. verpleging J 1.73 23 m²

V ERKEERSRUIMT E lift J 1.L27 10 m²

DA GCENT RUM 2 receptie/ balie J 1.115B 18 m²

DA GCENT RUM 2 wachtruimte H1.100W 23 m² DA GCENT RUM 2 huisk amer H1.29 45 m²

DA GCENT RUM 2 spreek k amer H1.05 11 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.33A 4 m²

MK ( UNIT B 1+ B 2) opsl. verpl. hulpm. J 1.11 11 m²

MK ( UNIT B 1+ B 2) opslag linnen J 1.04 5 m²

MK ( UNIT B 1+ B 2) opslag app. J 1.13 9 m²

MK ( CV ) spreek k amer J 1.21 14 m²

MK ( UNIT B 1+ B 2) opslag ( niet) steriel J 1.19 13 m²

MK ( DA GV ERPL.) sluis J 1.79B 4 m²

J 1.06A MK ( UNIT B 1+ B 2) voorruimte toiletten pers. J 1.06 3 m²

MK ( DA GV ERPL.) voorruimte toiletten bez . J 1.35 6 m²

T ECHNIEK trafo J 1.E1 1 m²

MK ( DA GV ERPL.) opslag linnen J 1.53 5 m²

?

T ECHNIEK schacht J 1.S01 6 m²

MK ( DA GV ERPL.) voorr. toiletten pat. J 1.59 3 m²

MK ( DA GV ERPL.) pantry J 1.105A 7 m²

DA GCENT RUM 2 5p. verpleging H1.35 50 m² DA GCENT RUM 2 1p. verpleging H1.39 21 m²

DA GCENT RUM 2 5p. verpleging H1.23 50 m²

V ERKEERSRUIMT E gang J 1.115V 52 m² DA GCENT RUM 2 MIV A toilet pat. H1.07 5 m²

KINDERV ERPLEGING ( CV ) satelliet apotheek J 1.29 25 m²

J 1.59A

J 1.61A

DA GCENT RUM 2 teampost H1.17 11 m²

MK ( DA GV ERPL.) behandelk amer J 1.75 17 m²

MK ( DA GV ERPL.) opslag steriel/ niet steriel J 1.81 12 m²

MK ( CV ) spreek k amer J 1.83 10 m²

DA GCENT RUM 2 sanitair alg. H1.29A 1 m²

DA GCENT RUM 2 sanitair pers. H1.25 1 m²

DA GCENT RUM 2 sanitair 1p H1.39A 3 m²

DA GCENT RUM 2 sanitair pers. H1.37 1 m²

DA GCENT RUM 2 teampost H1.31 11 m²

OK COMPLEX KL. CIRC. ontvangst emballage H1.104V 34 m²

MK ( DA GV ERPL.) spoelruimte J 1.69 11 m²

T ECHNIEK SER- ruimte J 1.P2 11 m²

MK ( DA GV ERPL.) wachtruimte J 1.63 18 m²

12

n8 13

MK ( UNIT B 1+ B 2) supervisorenruimte J 1.87 30 m²

MK ( CV ) multifunct. overlegruimte J 1.85 23 m²

MK ( DA GV ERPL.) werk r. ( unith.) J 1.77 10 m²

J 1.71A MK ( DA GV ERPL.) voorr. toiletten pers. J 1.71 4 m²

14n9

DA GCENT RUM 2 pantry H1.47 10 m²

T ECHNIEK schacht H1.S01 5 m²

J 1.61B

5760 MK ( CV ) MIV A toilet bez . J 1.55 6 m²

MK ( UNIT B 1+ B 2) MIV A douche J 1.08B 4 m²

DA GCENT RUM 2 sanitair 5p H1.15A 4 m²

T ECHNIEK trafo J 1.E3 1 m²

MK ( DA GV ERPL.) voorr. toiletten pat. J 1.61 3 m² MK ( DA GV ERPL.) opslag rolstoel J 1.67 6 m²

T ECHNIEK schacht J 1.S03 5 m²

MK ( DA GV ERPL.) teampost J 1.45 32 m²

MK ( UNIT B 1+ B 2) MIV A toilet + douche J 1.31A 5 m²

MK ( UNIT B 1+ B 2) MIV A toilet bez . J 1.08A 4 m² MK ( UNIT B 1+ B 2) toilet + douche J 1.12A 5 m²

?

MK ( CV ) opslag overig J 1.27 7 m²

MK ( UNIT B 1+ B 2) artsen/ ass. k amer J 1.10 23 m²

V ERKEERSRUIMT E trappenhuis J 1.T 22 14 m²

3180

J 1.06B

MK ( UNIT B 1+ B 2) 4p. verpleging J 1.08 49 m²

KINDERV ERPLEGING sanitair J 1.79A 3 m²

MK ( UNIT B 1+ B 2) behandelk amer J 1.23 15 m²

900

MK ( CV ) opslag reanim. + defib. J 1.02 4 m²

T ECHNIEK SER- ruimte J 1.P1 10 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.03A 4 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.03 19 m²

900

DA GCENT RUM 2 5p. verpleging H1.15 51 m² MK ( UNIT B 1+ B 2) sluis J 1.33B 4 m²

900

MK ( UNIT B 1+ B 2) toilet + douche J 1.05A 5 m²

900

MK ( UNIT B 1+ B 2) toilet + douche J 1.01A 5 m²

DA GCENT RUM 2 schone werk ruimte H1.43 9 m²

T ECHNIEK E- k ast H1.E1 2 m²

T ECHNIEK schacht J 1.S09 3 m²

DA GCENT RUM 2 werk k ast H1.49 2 m²

n10

15

DA GCENT RUM 2 spoelruimte H1.45 7 m²

DA GCENT RUM 2 opslag algemeen H1.51 6 m²

DA GCENT RUM 2 recovery/ holding ( k ind) H1.18 53 m²

DA GCENT RUM 2 sedatie H1.18E 12 m²

DA GCENT RUM 2 opslag linnen H1.53 6 m²

DA GCENT RUM 2 back office dagcentrum H1.41 32 m²

J 1.71B DA GCENT RUM 2 opslag scopen H1.14 2 m²

MK ( CV ) werk r. ( unith.) J 1.20 11 m²

3005

MK ( UNIT B 1+ B 2) werk k ast J 1.18 5 m²

T ECHNIEK E- k ast J 1.E2 3 m²

3250 DA GCENT RUM 2 teampost H1.18D 10 m²

DA GCENT RUM 2 schone werk ruimte H1.18C 7 m²

OK COMPLEX KL. CIRC. steriele lift H1.L28 3 m²

OK 16 tech. 19" rack H1.20 2 m²

OK COMPLEX KL. CIRC. steriele lift H1.L29 3 m²

DA GCENT RUM 2 back office dagcentrum H1.41A 7 m²

DA GCENT RUM 2 recovery/ holding ( 6 plek k en) + schone werk ruimte+ teampost+ opslag algemeen H1.65 99 m²

DA GCENT RUM 2 spoelruimte H1.65A 7 m²

DA GCENT RUM 2 k leedruimte H1.55A 4 m²

DA GCENT RUM 2 k leedruimte H1.55B 4 m²

DA GCENT RUM 2 sluis voorbehandeling H1.55C 5 m² DA GCENT RUM 2 voorbehandeling druppelruimte H1.55 39 m²

MK ( UNIT B 1+ B 2) 2p. verpleging HC J 1.28 26 m²

MK ( UNIT B 1+ B 2) pantry J 1.26 13 m²

MK ( UNIT B 1+ B 2) sluis J 1.22B 3 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.22A 4 m²

MK ( DA GV ERPL.) multifunct. ruimte J 1.93 20 m²

V ERKEERSRUIMT E lift J 1.L24 8 m²

MK ( UNIT A 1+ A 2) snoez elk amer J 1.95 17 m²

MK ( UNIT B 1+ B 2) opslag k nutselsp. J 1.95A 9 m²

DA GCENT RUM 2 wasruimte H1.106B 1 m²

MK ( DA GV ERPL.) speelk amer J 1.97 31 m²

MK ( UNIT B 1+ B 2) MIV A toilet + douche J 1.28A 5 m²

DA GCENT RUM 2 recovery H1.24 26 m²

DA GCENT RUM 2 OK ( snel circuit k ind) H1.26 33 m²

455

50 400

nF

MK ( UNIT B 1+ B 2) ber. borstv. J 1.24 9 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.22 16 m²

295

2563

DA GCENT RUM 2 opslag linnen H1.18A 2 m²

DA GCENT RUM 2 spoelruimte H1.18B 6 m²

450

900 DA GCENT RUM 2 werk k ast H1.16 2 m²

V ERKEERSRUIMT E trap J 1.T 26 1 m²

500

V ERKEERSRUIMT E gang J 1.113V 28 m²

MK ( CV ) receptie/ secretariaat J 1.47 20 m²

500

MK ( DA GV ERPL.) 4p. verpleging J 1.41 42 m²

550

MK ( UNIT B 1+ B 2) 1 persoonsk amer X L J 1.31 24 m²

MK ( UNIT B 1+ B 2) teampost J 1.14 34 m²

96.7 102.8 86.1

MK ( UNIT B 1+ B 2) artsen/ ass. k amer J 1.16 19 m² MK ( UNIT B 1+ B 2) 1p. verpleging J 1.12 23 m²

V ERKEERSRUIMT E lift J 1.L25 8 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.32A 4 m²

MK ( DA GV ERPL.) tienerhuisk amer J 1.91 23 m²

MK ( UNIT B 1+ B 2) spoelruimte J 1.30 15 m²

MK ( UNIT A 1+ A 2) opslag speelgoed J 1.99A 5 m²

MK ( UNIT B 1+ B 2) 1p. verpleging HC J 1.34 25 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.32 19 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.34A 4 m²

DA GCENT RUM 2 OK ( k lasse 1, snel circuit) H1.69 29 m²

DA GCENT RUM 2 OK ( k lasse 1, snel circuit) H1.67 29 m²

V ERKEERSRUIMT E gang H1.112V 109 m²

MK ( DA GV ERPL.) speelk amer J 1.99 32 m²

DA GCENT RUM 2 technische ruimte H1.E12 2 m²

? ?

nE ??

DA GCENT RUM 2 receptie k ind 3 wp. H1.30 13 m²

DA GCENT RUM 2 inleiden k ind H1.28 18 m²

DA GCENT RUM 2 opdek ruimte ( OK snel circuit) H1.71 17 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.36 19 m²

MK ( UNIT B 1+ B 2) sluis J 1.40B 6 m²

MK ( CV ) afdelingsk euk en J 1.38 31 m²

MK ( UNIT B 1+ B 2) 1p. verpleging HC J 1.40 19 m² ? ?

V ERKEERSRUIMT E trappenhuis J 1.T 23 14 m²

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

MK ( UNIT B 1+ B 2) toilet + douche J 1.50A 4 m²

8100

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

V T _ WM15( PL02) : belasting/ gewicht MA X . 1200k g

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.116 22 m²

MK ( UNIT A 1+ A 2) pantry J 1.110 13 m²

MK ( UNIT A 1+ A 2) spoelruimte J 1.76 16 m²

MK ( UNIT A 1+ A 2) behandelk amer J 1.80 18 m²

MK ( UNIT A 1+ A 2) ber. borstv. J 1.84 10 m²

MK ( UNIT A 1+ A 2) MIV A douche J 1.88B 4 m²

MK ( UNIT A 1+ A 2) MIV A toilet J 1.88A 4 m²

MK ( UNIT A 1+ A 2) sluis J 1.94B 4 m²

MK ( UNIT A 1+ A 2) 2p. verpleging J 1.126 31 m²

MK ( UNIT A 1+ A 2) 2p. verpleging J 1.124 31 m²

MK ( UNIT A 1+ A 2) 1 persoonsk amer X L J 1.132 27 m²

MK ( UNIT A 1+ A 2) 1 persoonsk amer X L J 1.134 29 m²

MK ( UNIT A 1+ A 2) 1 persoonsk amer X L J 1.138 27 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.116A 4 m²

MK ( UNIT A 1+ A 2) werk k ast J 1.120 2 m²

MK ( UNIT A 1+ A 2) MIV A toilet + douche J 1.126A 5 m²

MK ( UNIT A 1+ A 2) MIV A toilet + douche J 1.124A 5 m²

2563

MK ( UNIT A 1+ A 2) toilet + douche J 1.68A 4 m²

600

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.74 18 m²

295

MK ( UNIT A 1+ A 2) toilet + douche J 1.90A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.82A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.74A 4 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.68 19 m²

50

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.82 19 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.78 18 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.78A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.86A 4 m²

DA GCENT RUM 2 OK ( k ind groot) H1.56 45 m²

DA GCENT RUM 2 reanimatiek ar H1.107B 1 m²

DA GCENT RUM 2 berging apparatuur H1.60 44 m²

MK ( CV ) werk r. ( unith.) J 1.102 13 m²

DA GCENT RUM 2 opslag schoonmaak app. H1.99 12 m²

MK ( UNIT A 1+ A 2) artsen/ ass. k amer J 1.118 17 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.122 15 m²

OK 12 technische ruimte H1.93 1 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.130 19 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.136 19 m²

V ERKEERSRUIMT E trap H1.T 30 5 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.140 18 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.136A 4 m²

MK ( CV ) spreek k amer J 1.146 13 m²

DA GCENT RUM 2 k leedruimte Heren ( incl. douche en 3 toiletten) H1.66 47 m²

DA GCENT RUM 2 OK ( generiek ) H1.97 45 m²

DA GCENT RUM 2 wasruimte H1.95 7 m²

DA GCENT RUM 2 wasruimte H1.95 7 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.140A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.130A 4 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.128 19 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.128A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.92A 4 m²

DA GCENT RUM 2 opdek ruimte ( volwassen) H1.91 15 m²

DA GCENT RUM 2 vuilk ar OK H1.107C 1 m²

V ERKEERSRUIMT E gang H1.106V .2 6 m²

DA GCENT RUM 2 opdek ruimte H1.58 12 m²

MK ( UNIT A 1+ A 2) sluis J 1.122B 3 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.100 18 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.92 19 m²

DA GCENT RUM 2 OK ( generiek ) H1.87 45 m²

DA GCENT RUM 2 inleiden k ind H1.54 14 m² T ECHNIEK schacht J 1.S08 4 m²

MK ( UNIT A 1+ A 2) sanitair J 1.134A 5 m² T ECHNIEK E- k ast J 1.E8 2 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.122A 4 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.100A 4 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.90 19 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.86 19 m²

DA GCENT RUM 2 wasruimte H1.85 7 m²

DA GCENT RUM 2 wasruimte H1.85 7 m²

T ECHNIEK E- k ast H1.E2 3 m²

MK ( UNIT A 1+ A 2) sanitair J 1.138A 5 m²

MK ( UNIT A 1+ A 2) sanitair J 1.132A 5 m²

MK ( UNIT A 1+ A 2) wasruimte J 1.120V A 1 m²

400

OK 11 technische ruimte H1.83 1 m²

DA GCENT RUM 2 berging anesthesie H1.89 20 m²

DA GCENT RUM 2 wasruimte H1.106F 1 m²

J 1.142B

MK ( UNIT A 1+ A 2) voorr. toiletten pers. J 1.142 8 m²

MK ( UNIT A 1+ A 2) sluis J 1.116B 6 m²

T ECHNIEK schacht J 1.S06 7 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.62 19 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.64A 4 m²

DA GCENT RUM 2 vuilk ar OK H1.107A 1 m²

T ECHNIEK schacht H1.S03 4 m²

DA GCENT RUM 2 opdek ruimte H1.48 12 m²

J 1.142A

1024

J 1.112A

MK ( UNIT A 1+ A 2) toilet + douche J 1.94A 4 m²

T ECHNIEK trafo J 1.E6 1 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.64 24 m²

250

DA GCENT RUM 2 OK ( k ind groot) H1.46 45 m²

KINDERV ERPLEGING ( CV ) satelliet apotheek J 1.96 27 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.94 22 m²

J 1.112

MK ( UNIT A 1+ A 2) opsl. verpl. hulpm. J 1.72 10 m²

MK ( UNIT A 1+ A 2) opslag app. J 1.70 9 m²

DA GCENT RUM 2 werk k ast H1.73 5 m²

DA GCENT RUM 2 opslag ( snel circuit) H1.75 6 m²

DA GCENT RUM 2 opdek ruimte ( volwassen) H1.81 15 m²

1032

MK ( UNIT A 1+ A 2) 4p. verpleging J 1.88 54 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.62A 4 m²

OK 9+ 10 tech. 19" rack H1.73A 1 m²

DA GCENT RUM 2 berging schoon H1.77 14 m²

DA GCENT RUM 2 inleiden k ind H1.44 14 m²

1024

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.60 19 m²

DA GCENT RUM 2 vuilk ar OK H1.109B 1 m²

DA GCENT RUM 2 sluis vuil H1.36 25 m²

MK ( UNIT A 1+ A 2) opslag steriel/ niet steriel J 1.56 16 m²

T ECHNIEK E- k ast J 1.E4 2 m²

MK ( UNIT A 1+ A 2) opslag linnen J 1.58 7 m²

570

MK ( UNIT A 1+ A 2) toilet + douche J 1.60A 4 m²

OK COMPLEX KL. CIRC. steriele berging H1.40 189 m²

DA GCENT RUM 2 wasruimte H1.109A 1 m²

n10 n10

15

1022

V ERKEERSRUIMT E gang J 1.112V 67 m²

T ECHNIEK schacht J 1.S02 6 m²

MK ( UNIT A 1+ A 2) opslag speelgoed J 1.54 9 m²

n9 14n9

DA GCENT RUM 2 technische ruimte H1.E14 1 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.50 23 m²

MK ( UNIT A 1+ A 2) toilet + douche J 1.52A 4 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.52 19 m²

n8 n8 13

12

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.46 21 m²

MK ( UNIT B 1+ B 2) sluis J 1.46B 3 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.48A 4 m²

DA GCENT RUM 2 sluis k ind in H1.34 27 m²

atrium 02 J 1.V 2 236 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.46A 4 m²

MK ( UNIT A 1+ A 2) badk amer ( bed + rolstoel) J 1.42 14 m²

MK ( UNIT B 1+ B 2) 1p. verpleging J 1.44 19 m²

MK ( UNIT A 1+ A 2) 1p. verpleging J 1.48 19 m²

??

MK ( UNIT B 1+ B 2) toilet + douche J 1.40A 4 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.44A 4 m²

MK ( UNIT B 1+ B 2) toilet + douche J 1.36A 4 m²

? ? H1.66D??

H1.66B

DA GCENT RUM 2 DA GCENT RUM 2 DA 2GCENT RUM 2 DA GCENT RUM DA 2GCENT RUM 2 DA GCENT RUM toilet toilet douche toilet toilet toilet H1.76A H1.66A H1.76E H1.76D 1 m² H1.76B 1 m² H1.76C 1 m² 1 m² 1 m² 1 m²

DA GCENT RUM 2 back office anest. en aanlandplek k en H1.96C DA GCENT RUM 2 5 m² back office anest. en aanlandplek k en H1.96D 5 m²

DA GCENT RUM 2 DA GCENT RUM 2 back office anest. back office anest. en aanlandplek k en H1.96A H1.96B 4 m² 5 m²

DA GCENT RUM 2 back office anest. en aanlandplek k en H1.96E 16 m²

DA GCENT RUM 2 k leedruimte Dames ( incl. douche en 4 toiletten) H1.76 53 m²

DA GCENT RUM 2 back office anest. en aanlandplek k en H1.96 33 m²

882

First floor plan Design sketches

Exterior view with access to parking garage | View across the pond | Façade of the extension

podium. Part of the reconstruction project was a thorough upgrade of the high-rise slab, realized by Architecten aan de Maas, and an extension of the horizontal podium. Covering an area of 34,500 m2, the new section accommodates anesthesiology, oncology, hematology and a day-patient clinic (AOHD), as well as operating theaters, the Juliana Children’s Hospital and the Motherand-Child Center. The contrast between the hard, industrial character of the existing building and the soft, rounded corners of the children’s hospital is hard to miss. This new wing evokes the serenity of Art Deco architecture. Clearly, the Juliana Children’s Hospital is designed as

a signature building that puts the children at the center. This was one of the client’s main goals, and not surprisingly the Planetree concept was the primary source of inspiration. All care and cure processes are organized according to Planetree principles. The Juliana Children’s Hospital has direct access to a surrounding garden, designed by landscape architects Karres + Brands, which is visually linked to abundant greenery inside, mostly potted plants. Research suggested that whereas their parents prefer views on the park, the children like to see people moving around in the squares and

the main street. Studies have shown that a child-friendly environment can provide distraction and reduce anxiety and the perception of pain. This contributes toward creating a more positive hospital experience. Discussions with a number of user groups, which included groups of children, provided valuable information on how they experienced various hospital spaces. MVSA invited the experience design agency Tinker Imagineers to create a ‘moving’ storyline for the Juliana Kinderziekenhuis. Five cuddly characters – Hugg, Happy, Fold, C-bot and Fizzle – come to life all around the

JULIANA CHILDREN’S HOSPITAL

169

894

1032

MA T + OB S MIV A sanitair J 2.03A 5 m²

MA T + OB S k raamsuite J 2.05 19 m²

895

892

1032

895

MA T + OB S k raamsuite J 2.15 19 m²

MA T + OB S k raamsuite J 2.11 19 m²

MA T + OB S k raamsuite J 2.07 19 m²

MA T + OB S verlosk amer J 2.21 29 m²

MA T + OB S k raamsuite J 2.03 22 m²

MA T + OB S MIV A sanitair J 2.07A 5 m²

MA T + OB S MIV A sanitair J 2.05A 5 m²

MA T + OB S MIV A sanitair J 2.11A 5 m²

MA T + OB S verlosk amer J 2.23 30 m²

V ERKEERSRUIMT E loopbrug E2.120V 231 m²

MA T + OB S MIV A sanitair J 2.15A 5 m²

895

895

895

895

895

V ERKEERSRUIMT E loopbrug E2.120V 231 m²

895 ? ? ??

MA T + OB S werk r. ( unith.) J 2.01 11 m²

MA T + OB S schone werk ruimte J 2.09 8 m²

V ERKEERSRUIMT E lift J 2.L26 10 m²

MA T + OB S MIV A sanitair J 2.23A 5 m²

MA T + OB S MIV A sanitair J 2.21A 5 m²

V ERLOSK. + NEONA T O. k olfruimte J 2.17 6 m²

MA T + OB S 3p. verpleging J 2.65 36 m²

V ERKEERSRUIMT E lift J 2.L27 10 m²

OK COMPLEX KL. CIRC. receptie/ balie H2.01 17 m²

OK COMPLEX KL. CIRC. spreek k amer H2.03 12 m²

OK COMPLEX KL. CIRC. sanitair H2.05 2 m²

T ECHNIEK E- k ast J 2.E5 2 m²

MA T + OB S 2p. verpleging J 2.73 32 m² V ERLOSK. + NEONA T O. opslag en reiniging bedden J 2.75 69 m²

V ERKEERSRUIMT E gang J 2.101V 106 m²

MA T + OB S k raamsuite J 2.02 17 m²

MA T + OB S verlosk amer J 2.35 29 m²

MA T + OB S verlosk amer J 2.45 29 m²

MA T + OB S verlosk amer J 2.39 29 m²

OK COMPLEX KL. CIRC. recovery/ holding ( 11 plek k en) H2.25 157 m²

MA T + OB S verlosk amer J 2.59 25 m²

MA T + OB S verlosk amer J 2.55 29 m²

MA T + OB S verlosk amer J 2.49 29 m²

V ERLOSK. + NEONA T O. sanitair J 2.73A 4 m²

MA T + OB S MIV A sanitair J 2.02A 4 m²

V ERKEERSRUIMT E gang J 2.115V 88 m²

V ERLOSK. + NEONA T O. sluis J 2.59B 4 m²

MA T + OB S opslag verpl. hulpm. J 2.19 15 m²

MA T + OB S ( niet) steriele opslag J 2.13 14 m²

MA T + OB S MIV A sanitair J 2.35A 5 m²

V ERLOSK. + NEONA T O. satelliet apotheek J 2.27 15 m²

MA T + OB S MIV A sanitair J 2.39A 5 m²

MA T + OB S MIV A sanitair J 2.45A 5 m²

OK COMPLEX KL. CIRC. centrale post H2.19 32 m²

MA T + OB S MIV A sanitair J 2.55A 5 m²

MA T + OB S MIV A sanitair J 2.49A 5 m²

OK COMPLEX KL. CIRC. recovery ( PA CU) H2.25A 51 m²

OK COMPLEX KL. CIRC. sluis patienten uit/ in H2.07 23 m² T ECHNIEK SER- ruimte J 2.P2 11 m²

MA T + OB S opslag verpl. hulpm. J 2.83 17 m²

MA T + OB S MIV A sanitair J 2.59A 4 m²

V ERLOSK. + NEONA T O. sanitair J 2.65A 4 m²

V ERLOSK. + NEONA T O. opslag linnen J 2.69 4 m²

OK COMPLEX KL. CIRC. opdek ruimte H2.33 14 m²

OK COMPLEX KL. CIRC. schone werk ruimte H2.21 14 m² OK COMPLEX KL. CIRC. spoelruimte H2.27 13 m²

OK COMPLEX KL. CIRC. isolatie H2.09 20 m²

V ERLOSK. + NEONA T O. werk k ast J 2.85 3 m²

T ECHNIEK trafo J 2.E1 4 m²

MA T + OB S k raamsuite J 2.04 18 m²

OK COMPLEX KL. CIRC. wasruimte H2.37 7 m²

MA T + OB S MIV A sanitair J 2.04A 5 m²

V ERLOSK. + NEONA T O. sluis J 2.47B 4 m²

MA T + OB S schone werk ruimte J 2.43 9 m²

MA T + OB S spoelruimte J 2.33 10 m²

MA T + OB S afdelingsk euk en J 2.29 29 m²

T ECHNIEK schacht J 2.S03 5 m²

MA T + OB S teampost J 2.53 28 m²

1030

T ECHNIEK schacht J 2.S01 6 m²

MA T + OB S k raamsuite J 2.06 18 m²

MA T + OB S MIV A sanitair J 2.31A 5 m²

MA T + OB S pantry J 2.10 17 m²

MA T + OB S spoelruimte J 2.12 10 m²

1032

1032

OK COMPLEX KL. CIRC. techn. Siemens H2.12 7 m²

T ECHNIEK schacht J 2.S09 3 m² MA T + OB S verlosk amer J 2.71 30 m²

MA T + OB S onderz oek sk amer J 2.67 14 m²

MA T + OB S verlosk amer J 2.77 31 m²

OK COMPLEX KL. CIRC. omk leden OK J 2.91 3 m²

OK COMPLEX KL. CIRC. steriele lift H2.L29 3 m²

V ERKEERSRUIMT E gang H2.102V 47 m²

OK COMPLEX KL. CIRC. interventie H2.24 10 m²

V ERKEERSRUIMT E lift J 2.L25 8 m²

MA T + OB S 1p. verpleging J 2.30 18 m²

V ERKEERSRUIMT E gang H2.22V 18 m²

OK COMPLEX KL. CIRC. techn. Siemens H2.28 6 m²

MA T + OB S MIV A sanitair J 2.26A 5 m²

atrium 01 J 2.V 1 265 m²

V ERKEERSRUIMT E gang J 2.108V 92 m²

MA T + OB S familiek amer J 2.109W.1 10 m²

V ERKEERSRUIMT E gang H2.104V 132 m²

OK COMPLEX KL. CIRC. bedienruimte H2.20 12 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

MA T + OB S k raamsuite J 2.26 17 m²

MA T + OB S MIV A sanitair J 2.22A 5 m²

OK COMPLEX KL. CIRC. opdek ruimte H2.53 15 m² OK COMPLEX KL. CIRC. steriele berging H2.32 96 m²

OK COMPLEX KL. CIRC. wasruimte H2.57 7 m²

V ERKEERSRUIMT E gang H2.106V 24 m²

OK COMPLEX KL. CIRC. bedienruimte H2.30 12 m²

V ERKEERSRUIMT E gang J 2.109V 147 m²

V ERKEERSRUIMT E gang H2.105V 89 m²

OK COMPLEX KL. CIRC. sluis ( incl. wassen en opslag loodschorten) H2.26 11 m²

V ERKEERSRUIMT E gang J 2.106V 35 m²

MA T + OB S MIV A sanitair J 2.28A 5 m²

OK COMPLEX KL. CIRC. technische ruimte H2.E15 0 m²

OK COMPLEX KL. CIRC. opdek ruimte H2.63 15 m²

OK COMPLEX KL. CIRC. opslag app. H2.40 69 m²

OK COMPLEX KL. CIRC. voorbereidingsruimte H2.34 11 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

MA T + OB S k raamsuite J 2.28 17 m²

? ??

OK COMPLEX KL. CIRC. OK ( cardio) H2.65 45 m²

J 2.34A OK COMPLEX KL. CIRC. wasruimte H2.67 7 m²

OK COMPLEX KL. CIRC. interventie/ angiok amer 2 H2.36 49 m²

MA T + OB S MIV A sanitair J 2.32A 5 m²

MA T + OB S familiek amer J 2.109W.2 13 m²

MA T + OB S k raamsuite J 2.38 17 m²

V ERLOSK. + NEONA T O. dames toiletten/ lock ers J 2.36 11 m² MA T + OB S 1p. verpleging J 2.32 18 m²

OK COMPLEX KL. CIRC. inleiden k ind/ reanimatie H2.38 27 m²

MA T + OB S MIV A sanitair J 2.38A 5 m²

OK COMPLEX KL. CIRC. opslag schoon H2.42 24 m²

?

OK COMPLEX KL. CIRC. wasruimte H2.67 7 m²

OK COMPLEX KL. CIRC. opslag anesthesie materiaal H2.71 24 m² OK COMPLEX KL. CIRC. technische ruimte H2.E17 0 m²

OK COMPLEX KL. CIRC. technische ruimte H2.E14 1 m² MA T + OB S MIV A sanitair J 2.40A 5 m²

OK COMPLEX KL. CIRC. opdek ruimte H2.73 15 m²

MA T + OB S MIV A sanitair J 2.46A 5 m²

V ERKEERSRUIMT E trappenhuis J 2.T 23 14 m²

MA T + OB S 1p. verpleging J 2.40 18 m²

MA T + OB S k raamsuite J 2.46 17 m²

OK COMPLEX KL. CIRC. opslag schoonmaak app. H2.60 14 m² NEONA T O. balie J 2.112B 18 m²

T ECHNIEK schacht J 2.S02 6 m² T ECHNIEK E- k ast J 2.E4 2 m²

NEONA T O. opslag verpl. hulpm. J 2.56 8 m²

MA T + OB S MIV A sanitair J 2.42A 5 m²

MA T + OB S 1p. verpleging J 2.52 18 m²

V ERLOSK. + NEONA T O. z uigelingen k euk en J 2.68A 10 m²

V ERKEERSRUIMT E gang J 2.112V 48 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

V T _ PL02: belasting/ gewicht MA X . 1200k g

V ERKEERSRUIMT E gang J 2.118V 78 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

T ECHNIEK UPS J 2.58A 2 m²

NEONA T O. spoelruimte J 2.72 10 m²

NEONA T O. couveuse suite ( meerl.) J 2.90 25 m²

NEONA T O. couveusez aal J 2.84 38 m²

NEONA T O. schone werk ruimte+ steriele/ niet - steriele opslag J 2.74 18 m²

V ERLOSK. + NEONA T O. z uigelingen k euk en J 2.68 14 m²

T ECHNIEK schacht H2.S03 7 m²

NEONA T O. couveuse suite J 2.124 19 m²

NEONA T O. teampost J 2.104 30 m²

T ECHNIEK schacht J 2.S06 7 m²

T ECHNIEK schacht J 2.S08 2 m²

NEONA T O. opslag app. J 2.148 9 m²

OK COMPLEX KL. CIRC. OK ( cardio) H2.75 45 m²

OK COMPLEX KL. CIRC. opdek ruimte ( hybride) H2.83 16 m²

OK COMPLEX KL. CIRC. wasruimte ( hybride) H2.54 7 m²

OK COMPLEX KL. CIRC. technische ruimte hybride o.k . H2.50 12 m²

T ECHNIEK E- k ast J 2.E8 3 m²

V ERKEERSRUIMT E gang J 2.120V 74 m²

NEONA T O. sluis J 2.122B 2 m²

V ERKEERSRUIMT E gang J 2.116V 34 m²

V ERKEERSRUIMT E gang J 2.114V 58 m²

OK COMPLEX KL. CIRC. wasruimte ( hybride) H2.54 7 m²

NEONA T O. couveusez aal J 2.138 38 m²

V ERLOSK. + NEONA T O. satelliet apotheek J 2.130 28 m²

NEONA T O. sluis J 2.124B 3 m²

NEONA T O. opslag linnen J 2.120 3 m²

OK COMPLEX KL. CIRC. wasruimte H2.77 7 m²

V ERKEERSRUIMT E gang H2.108V 31 m²

OK COMPLEX KL. CIRC. technische ruimte H2.E16 1 m²

NEONA T O. couveuse suite ( meerl.) J 2.144 25 m² NEONA T O. acute reanimatie suite J 2.128 19 m²

V T 100mm k orter ivm schuifdeur

NEONA T O. pantry J 2.100 7 m²

T ECHNIEK schacht H2.S05 3 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

NEONA T O. sanitair J 2.124A 4 m²

V ERLOSK. + NEONA T O. spreek k amer J 2.114 12 m² NEONA T O. flex. open werk plek J 2.94 27 m²

NEONA T O. sanitair J 2.90A 4 m²

V ERKEERSRUIMT E gang H2.107V 92 m²

OK COMPLEX KL. CIRC. IDKF werk plaats H2.62 14 m²

OK COMPLEX KL. CIRC. wasruimte H2.44 7 m²

OK COMPLEX KL. CIRC. OK ( spoed sectio) H2.46 53 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

OK COMPLEX KL. CIRC. opdek ruimte H2.48 16 m²

V ERKEERSRUIMT E gang J 2.110V 20 m²

MA T + OB S MIV A sanitair J 2.52A 5 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

V ERLOSK. + NEONA T O. opslag z uigelingenvoeding J 2.54 7 m²

NEONA T O. opslag echo/ rontg. J 2.58 1 m²

MA T + OB S MIV A sanitair J 2.50A 5 m²

MA T + OB S 1p. verpleging J 2.50 18 m²

V ERLOSK. + NEONA T O. spreek k amer J 2.48 11 m²

1275

MA T + OB S opslag linnen J 2.44 9 m² MA T + OB S 1p. verpleging J 2.42 18 m²

OK COMPLEX KL. CIRC. OK ( generiek ) H2.55 45 m²

OK COMPLEX KL. CIRC. wasruimte H2.57 7 m² ?

T ECHNIEK schacht H2.S04 3 m²

MA T + OB S MIV A sanitair J 2.30A 5 m²

OK COMPLEX KL. CIRC. OK ( urologie) H2.45 45 m²

OK COMPLEX KL. CIRC. opslag reanimatiek arren H2.104A 3 m²

V ERKEERSRUIMT E lift J 2.L24 8 m² MA T + OB S k raamsuite J 2.18 18 m²

MA T + OB S 1p. verpleging J 2.22 18 m²

OK COMPLEX KL. CIRC. wasruimte H2.47 7 m²

457 OK COMPLEX KL. CIRC. steriele lift H2.L28 3 m²

OK COMPLEX KL. CIRC. voorbereidingsruimte H2.18 11 m²

T ECHNIEK schacht H2.S02 3 m²

MA T + OB S MIV A sanitair J 2.18A 5 m²

V ERLOSK. + NEONA T O. multifunct. overlegr./ k offier. J 2.24 36 m²

OK COMPLEX KL. CIRC. opdek ruimte H2.43 15 m²

OK COMPLEX KL. CIRC. inleiden H2.15 64 m²

OK COMPLEX KL. CIRC. interventie/ angiok amer 1 H2.16 49 m²

OK COMPLEX KL. CIRC. overlegruimte H2.14 10 m²

MA T + OB S pantry J 2.57 9 m²

V ERKEERSRUIMT E gang J 2.107V 25 m²

MA T + OB S teampost J 2.16 19 m²

V ERKEERSRUIMT E gang J 2.102V 129 m²

OK COMPLEX KL. CIRC. wasruimte H2.37 7 m²

MA T + OB S verlosk amer J 2.87 30 m²

MA T + OB S verlosk amer J 2.81 31 m²

MA T + OB S balie J 2.109B 12 m²

1032

V ERKEERSRUIMT E gang J 2.104V 21 m²

MA T + OB S MIV A sanitair J 2.20A 5 m²

MA T + OB S flex. open werk plek J 2.51 16 m²

MA T + OB S k raamsuite J 2.47 18 m²

MA T + OB S k raamsuite J 2.41 18 m²

MA T + OB S k raamsuite J 2.37 18 m²

1032

T ECHNIEK schacht H2.S01 5 m²

OK COMPLEX KL. CIRC. goederensluis ( vuil) H2.10 30 m²

T ECHNIEK schacht J 2.S07 2 m²

MA T + OB S MIV A sanitair J 2.87A 5 m²

MA T + OB S MIV A sanitair J 2.81A 5 m²

MA T + OB S MIV A sanitair J 2.77A 5 m²

MA T + OB S MIV A sanitair J 2.71A 5 m²

MA T + OB S toilet J 2.67A 3 m²

J 2.63C

V ERLOSK. + NEONA T O. MIV A bez . toilet J 2.61 4 m²

T ECHNIEK E- k ast J 2.E2 3 m²

MA T + OB S MIV A sanitair J 2.08A 5 m²

J 2.63B

V ERLOSK. + NEONA T O. voorruimte toiletten bez . J 2.63 7 m²

T ECHNIEK SER- ruimte J 2.P1 11 m²

MA T + OB S flex. open werk plek J 2.14 15 m²

MA T + OB S k raamsuite J 2.31 18 m²

MA T + OB S 1p. verpleging J 2.20 18 m²

MA T + OB S MIV A sanitair J 2.47A 5 m²

MA T + OB S MIV A sanitair J 2.41A 5 m²

MA T + OB S MIV A sanitair J 2.37A 5 m²

J 2.63A

MA T + OB S MIV A sanitair J 2.06A 5 m²

MA T + OB S 1p. verpleging J 2.08 18 m²

OK COMPLEX KL. CIRC. OK ( urologie) H2.35 45 m²

V ERKEERSRUIMT E gang J 2.111V 74 m²

V ERKEERSRUIMT E gang J 2.105V 77 m² V ERKEERSRUIMT E trappenhuis J 2.T 22 14 m²

V ERKEERSRUIMT E gang H2.110V 6 m²

OK COMPLEX KL. CIRC. OK ( hybride) H2.56 70 m²

OK COMPLEX KL. CIRC. wasruimte H2.87 6 m² OK COMPLEX KL. CIRC. opdek ruimte ( hybride) H2.58 18 m²

OK COMPLEX KL. CIRC. perfusie H2.66 43 m²

DA GCENT RUM 2 back office pantry H2.76A 10 m²

OK COMPLEX KL. CIRC. OK ( vergrote generiek ) H2.85 71 m²

?

NEONA T O. sanitair J 2.82A 4 m²

MA T + OB S MIV A sanitair J 2.70A 4 m²

MA T + OB S 1p. verpleging J 2.60 21 m²

MA T + OB S k raamsuite J 2.66 19 m²

MA T + OB S k raamsuite J 2.70 18 m² MA T + OB S MIV A sanitair J 2.66A 4 m²

NEONA T O. sanitair J 2.92A 4 m²

NEONA T O. couveuse suite J 2.82 19 m²

NEONA T O. couveuse suite J 2.76 18 m²

NEONA T O. sanitair J 2.76A 4 m²

NEONA T O. sanitair J 2.102A 4 m²

NEONA T O. couveuse suite J 2.92 19 m²

NEONA T O. couveuse suite J 2.86 19 m²

NEONA T O. sanitair J 2.86A 4 m²

NEONA T O. flex. open werk plek ( artsen) J 2.106 12 m² NEONA T O. couveuse suite J 2.102 18 m²

NEONA T O. couveuse suite J 2.96 19 m²

NEONA T O. sanitair J 2.126A 4 m²

NEONA T O. flex. open werk plek ( artsen) J 2.116 12 m²

NEONA T O. couveuse suite J 2.126 19 m²

NEONA T O. couveuse suite J 2.122 15 m²

NEONA T O. sanitair J 2.96A 4 m²

NEONA T O. sanitair J 2.136A 4 m²

NEONA T O. sanitair J 2.122A 4 m²

NEONA T O. couveuse suite J 2.132 19 m²

NEONA T O. sanitair J 2.146A 4 m²

NEONA T O. couveuse suite J 2.136 19 m²

NEONA T O. sanitair J 2.132A 4 m²

NEONA T O. couveuse suite J 2.142 19 m²

NEONA T O. couveuse suite J 2.146 18 m²

NEONA T O. werk r. ( unith.) J 2.152 12 m²

OK COMPLEX KL. CIRC. technische ruimte eventueel toek omstige hybride ok H2.90 10 m² DA GCENT RUM 2 back office H2.72C 8 m²

NEONA T O. sanitair J 2.142A 4 m²

Second floor plan

View of atrium | The northern atrium with sport facilities and physiotherapy

children in unique, animated wall projections. They accompany children on their ‘adventure’ and make them laugh. A wall-sized digital screen that interacts with the children is probably the most striking example of the use of modern media. Abundant public spaces are distributed throughout the three connected volumes of the new building, two of which are organized around glazed patios of four floors and contain the new children’s hospital. In order to guarantee the children’s hospital direct access to its green surroundings, the operating theater that is also situated in the extension was transferred from the outer perim-

170

CHILDREN’S HOSPITALS

eter, where it was first planned, to the interior corridor. Thus the placement of the children’s hospital encourages the children and their parents to discover the world outside the patient wards. The patios are flooded with daylight and most destinations are visible from the public spaces. In the Juliana Kinderziekenhuis, transparency is key to wayfinding. The architects created a subdued color palette which is used throughout the total complex. This basic palette, consisting of different ‘whites’, ‘grays’ and a darker anthracite hue, brings brightness, clearness and tranquility to the environment.

To emphasize the identity of each care unit and different specialties such as radiology, policlinic and anesthesiology, accents of bright and strong colors were added. The inpatient department has mainly single bedrooms, which are spacious enough to allow parents to spend the night with their children. Wherever feasible, green roofs have been applied as a form of natural isolation. Continuous off-white horizontal bands with rounded corners, fluent spaces, a lavish use of glass and the whitish finish of the floors create a luminous, clear atmosphere that acts as the backdrop of furniture in bright colors.

GEB OORT EHOT EL werk k ast J 3.75 7 m²

V ERKEERSRUIMT E lift J 3.L26 10 m²

V ERKEERSRUIMT E lift J 3.L27 10 m² ? ? ??

GEB OORT EHOT EL wasm. en droogr. ( opslag linnen) J 3.81 5 m²

GEB OORT EHOT EL afval J 3.71 5 m²

GEB OORT EHOT EL sophok / wassen J 3.83 13 m² GEB OORT EHOT EL MIV A toilet bez . J 3.69 4 m²

OK COMPLEX KL. CIRC. SER o.k . H3.P1 10 m²

GEB OORT EHOT EL opslag algemeen J 3.85 10 m²

T ECHNIEK schacht J 3.S03 10 m²

GEB OORT EHOT EL echo- / voorlichtingsruimte J 3.67 17 m²

GEB OORT EHOT EL z usterpost J 3.45 28 m²

GEB OORT EHOT EL schone berging J 3.87 10 m²

GEB OORT EHOT EL douche J 3.91A 3 m²

J 3.91B

J 3.91C

T ECHNIEK E- k ast H3.E1 2 m²

GEB OORT EHOT EL verblij fk amer J 3.61 27 m²

GEB OORT EHOT EL verblij fk amer J 3.51 28 m²

T ECHNIEK schacht J 3.S01 6 m²

V ERKEERSRUIMT E gang J 3.115V 35 m²

? GEB OORT EHOT EL pantry J 3.47 6 m²

GEB OORT EHOT EL opslag voeding J 3.35 8 m² GEB OORT EHOT EL verblij fk amer J 3.01 39 m²

GEB OORT EHOT EL sanitair J 3.06A 4 m²

GEB OORT EHOT EL verblij fk amer J 3.11 29 m²

GEB OORT EHOT EL verblij fk amer J 3.21 30 m²

GEB OORT EHOT EL opslag J 3.49 6 m²

?

GEB OORT EHOT EL sanitair J 3.51A 4 m²

GEB OORT EHOT EL wachtruimte verlosk . ( incl. pick et) J 3.65 10 m²

V ERKEERSRUIMT E gang J 3.113V 6 m²

??

GEB OORT EHOT EL garderobe/ lock ers J 3.91 9 m²

GEB OORT EHOT EL wachtruimte J 3.89 7 m²

GEB OORT EHOT EL k antoor J 3.31 18 m²

V ERKEERSRUIMT E gang J 3.111V 58 m² GEB OORT EHOT EL sanitair J 3.11A 4 m²

GEB OORT EHOT EL sanitair J 3.01A 5 m²

GEB OORT EHOT EL SER- ruimte J 3.P1 8 m²

GEB OORT EHOT EL sanitair J 3.21A 4 m²

GEB OORT EHOT EL balie J 3.41 14 m²

T ECHNIEK E- k ast J 3.E2 2 m²

GEB OORT EHOT EL verblij fk amer J 3.06 36 m²

V ERKEERSRUIMT E gang J 3.105V 53 m²

V ERKEERSRUIMT E lift J 3.L24 8 m²

GEB OORT EHOT EL verblij fk amer J 3.10 27 m² GEB OORT EHOT EL sanitair J 3.10A 4 m²

V ERKEERSRUIMT E lift J 3.L25 8 m²

GEB OORT EHOT EL sanitair J 3.16A 4 m²

GEB OORT EHOT EL verblij fk amer J 3.16 27 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

V ERKEERSRUIMT E gang J 3.106V 81 m²

GEB OORT EHOT EL verblij fk amer J 3.20 27 m²

GEB OORT EHOT EL sanitair J 3.20A 4 m²

V ERKEERSRUIMT E trap J 3.T 24 21 m² atrium 01 J 3.V 1 396 m²

atrium 02 J 3.V 2 770 m²

V ERKEERSRUIMT E gang J 3.109V 174 m²

V ERKEERSRUIMT E gang H3.102V 60 m²

GEB OORT EHOT EL sanitair J 3.26A 4 m²

GEB OORT EHOT EL verblij fk amer J 3.26 28 m²

? ? ??

RONA LD MCDONA LD berging J 3.32A 10 m²

RONA LD MCDONA LD multifunct. huisk amer J 3.109W 66 m²

T ECHNIEK schacht J 3.S02 7 m²

T ECHNIEK E- k ast J 3.E4 2 m² DA GCENT RUM 2 SER o.k . H3.P2 10 m²

V T _ PL02: belasting/ gewicht MA X . 1200k g

V ERKEERSRUIMT E gang J 3.112V 78 m²

T ECHNIEK technische ruimte H3.T R4 T ECHNIEK 2001 m² technische ruimte H3.T R4 2001 m²

V ERKEERSRUIMT E gang J 3.118V 57 m² T ECHNIEK E- k ast H3.E2 2 m²

J 3.50A

RONA LD MCDONA LD MIV A toilet + toiletten bez . J 3.84 8 m²

J 3.50B

RONA LD MCDONA LD woonk euk en J 3.36 110 m²

RONA LD MCDONA LD wasruimte J 3.58 24 m²

RONA LD MCDONA LD archief J 3.62 16 m²

RONA LD MCDONA LD afval J 3.86 5 m² RONA LD MCDONA LD hotelk amer J 3.94 27 m²

RONA LD MCDONA LD multifunct. huisk amer J 3.72 42 m² J 3.84C

RONA LD MCDONA LD toilet pers. J 3.50 5 m²

J 3.84A

T ECHNIEK schacht J 3.S06 7 m²

J 3.84B

RONA LD MCDONA LD hotelk amer J 3.114 25 m²

RONA LD MCDONA LD hotelk amer J 3.104 27 m² RONA LD MCDONA LD toilet + douche J 3.104A 4 m²

RONA LD MCDONA LD toilet + douche J 3.94A 4 m²

600

RONA LD MCDONA LD toilet + douche J 3.96A 4 m²

829

824

1935

RONA LD MCDONA LD vrij willigersk amer J 3.76 32 m²

RONA LD MCDONA LD werk ruimte management J 3.66 16 m²

1935

824

T ECHNIEK schacht J 3.S08 4 m²

V ERKEERSRUIMT E gang H3.106V 35 m²

V ERKEERSRUIMT E gang J 3.120V 47 m²

RONA LD MCDONA LD lounge J 3.116V 44 m²

600

RONA LD MCDONA LD werk ruimte management J 3.64 16 m²

RONA LD MCDONA LD multifunct. ruimte J 3.56 32 m²

RONA LD MCDONA LD MIV A toilet + douche J 3.114A 5 m²

T ECHNIEK E- k ast J 3.E8 2 m²

900 V ERKEERSRUIMT E gang J 3.114V 47 m²

RONA LD MCDONA LD toilet + douche J 3.106A 4 m²

RONA LD MCDONA LD hotelk amer J 3.96 27 m²

RONA LD MCDONA LD toilet + douche J 3.116A 4 m²

RONA LD MCDONA LD hotelk amer J 3.106 27 m²

RONA LD MCDONA LD hotelk amer J 3.116 27 m²

829

Third floor plan

Atrium with view toward the spaces for physiotherapy | Interior street between the old and new building | Operating room | Corridor with artwork by Tinker Imagineers

JULIANA CHILDREN’S HOSPITAL

171

Northwest elevation

Mother-Child and Surgical Center Kaiser-Franz-JosefSpital

Architect

Nickl & Partner Architekten

Client

Stadt Wien, Wiener Krankenanstaltenverbund

Completion

2016

Floor area

39,860 m2

Capacity

258 beds

Vienna, Austria

172

CHILDREN’S HOSPITALS

The result of a 2008 design competition, the Mother-Child and Surgical Center acts as a catalyst in the reconstruction of an existing hospital complex that had lost the clarity of the original plan. The process of fragmentation and haphazard additions that often result in the mutilation of the architectural qualities is typical for old, large-scale medical facilities, and pavilion hospitals appear to be particularly vulnerable. The Kaiser-Franz-Josef-Spital was no exception. The Mother-Child and Surgical Center replaced six smaller pavilions that occupied the space between the main structure of the old hospital and the Triester Straße. Its orientation follows

t AA

Pflege 3 Stationen

C

OP / Entbindung / vpflege / Labor

0 E6

3m in. 0m E6

. 3m min

4 OG 3 OG

3m in. 0m E6

2 OG

E6 0m in. 1m

1 OG EG UG 4 OG 3m in. 0m E6

3m in. 0m E6

3m in. 0m E6

0 E6

3m in. 0m E6

3m in. 0m E6

3 OG

. 3m min 3m in. 0m E6

E60 min. 1m

E6 0m in. 1m

2 OG 1 OG

E60 min. 1m

3m in. 0m E6

E6 0m in. 1m

er- und entsorgung

E60 min. 1m

mbulanzen

E60 min. 1m

E6 0m in. 1m

3m in. 0m E6

3m in. 0m E6

A

3m in. 0m E6

5D

Pflege 4 Stationen

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the main axis of the historical complex, which runs perpendicular to this street. During a future phase, the remaining historical buildings are likely to be replaced by a new block similar to the Mother-Child and Surgical Center. Located on one side of it, the old building will make place for a green court, and the orientation of the complex will run parallel to the Triester Straße. The center anticipates this: the main traffic artery on the ground floor will connect directly to the future extension. The Center pays tribute to its historical setting and recreates the pavilion structure: gardens and roof gardens restore the lavish green qualities so characteristic of this type of

hospital which is now integrated in a complex increasing the density of the site – combining the two design objectives of achieving concentration while providing greenery and daylight. The new building reaches out to the city, both spatially and functionally: the wall that separated the original pavilions from the urban setting was torn down, and the people in the neighborhood are invited to enjoy the benefits of the gardens, which are open to the public. Promoted by the competition brief, this is part of the strategy to urbanize the hospital and integrate medical processes in everyday life.

Doing away with inefficient fragmentation of medical facilities was one of the main reasons for the new building, which integrates the former Gottfried von Preyer’sches Kinderspital. The outpatient departments are located on the ground floor. The first floor accommodates the maternity ward, an obstetrics unit, pediatric and gynecology wards, anesthesia, urology, central endoscopy, occupational medicine, the outpatient skin clinic and a central surgery department with eight operating theaters. The second, third and fourth floor accomodate thw one- and twobed patient rooms that offer views on the surroundings, while the staff workrooms face

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Figure ground plan

Roof terrace with a view toward the city

the landscaped courtyards. Optimum flexibility is achieved by a modular layout that can accommodate changes. Nickl & Partner specialize in what they call ‘healing architecture’, involving strategies to improve patient well-being, health outcomes and even shorter hospital stay. Principal designer Hans Nickl identifies light as an overriding theme in the entire building: the green patios ensure that light penetrates into the central areas and there is a large, bright, day-lit hall. The perforated façade of the new center visually refers to the adjacent buildings.

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Ann & Robert H. Lurie Children’s Hospital Chicago, Illinois, USA

Architect

ZGF Architects with Solomon Cordwell Buenz (SCB) and Anderson Mikos Architects

Client

Ann & Robert H. Lurie Children’s Hospital of Chicago

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CHILDREN’S HOSPITALS

Completion

2012

Floor area

116,590 m2

Capacity

288 beds

Replacing a much-appreciated predecessor that had served the families of Chicago for over a century, Ann & Robert H. Lurie Children’s Hospital of Chicago (formerly Children’s Memorial Hospital) left its original site and moved to the campus of its academic partner Northwestern University Feinberg School of Medicine. The proximity to other medical institutions, notably the Prentice Women’s Hospital, more than compensated for the disadvantages of the modest plot; its small size meant that the architects had to design a high-rise building as the brief called for almost twice as much space as at the previous location.

LEVEL 2 FLOOR PLAN Emergency Department 1 Lobby 2 Waiting room 3

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Three firms joined forces to make this happen: Zimmer Gunsul Frasca Architects (ZGF) contributed their expertise in healthcare architecture, Solomon Cordwell Buenz their longstanding expertise in high-rise buildings and Anderson Mikos Architects their in-depth knowledge of the client, for whom they had worked for more than 30 years. The architects used references to local history and culture to bridge the gap between the medical world and the living environment of most of its users, asking local museums and artists to contribute work for display in the new

building. One of the five themes that give identity to the different floors, therefore, celebrates the city; the others refer to the lake, the park, the woods and the prairie. Part of the building is furnished with benches made of wood from trees that were planted on the occasion of the famous Columbian Exposition of 1893, which celebrated the city of Chicago as crowning four centuries of American civilization (thus combining art and history). With its 23 floors, Lurie Children’s stands out thanks to its architecture. The exterior looks like two stacked blocks, with the one on top slightly off axis. This is no coincidence: it marks the division into two

distinct functional units. The lower block is dedicated to the outpatient clinics, diagnostics and the treatment departments. The two-storied entrance lobby was designed with a maritime theme in mind; the Shedd Aquarium bequeathed sculptures of a whale with a small calf that float above the visitors, and the café is shaped like a boat. The main traffic artery is on the second floor, which also connects the children’s hospital to the women’s hospital next door. The emergency department is on this floor as well, accessible by a dedicated set of elevators and drive-up ramps. Operating theaters, also connected by dedicated elevators, occupy the fifth and sixth floors.

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Sky garden | Tree house | View of second floor | View of third floor with diagnostics | Patient room | Family life

The block on top contains the inpatient rooms and the family sleeping area. A large interior ‘Crown Sky Garden’ on the 11th floor, designed by landscape architect Mikyoung Kim, gives visitors and patients a place for distraction. Here, they can feel the sun and mentally escape from the hospital environment. Specific elements of this garden were added to the program as a result of explicit wishes by the Kids Advisory Board, which gave the hospital’s main users, the children who sometimes have to spend a long time there, a say in the design process – incorporating their views is one of the extraordinary aspects of this project. With a cafeteria, a

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conference center, a gift shop and a chapel, the 11th floor acts as a social hub. A glass deck provides a view on the Sky Garden from the floor above. Color has been used to help parents find their way to the department they have to visit – either the acute care unit, the children’s emergency department, pediatric or neonatal intensive care or the day surgery unit. Outside, color also figures prominently: the façade is enriched with LED lights.

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ANN & ROBERT H. LURIE CHILDREN’S HOSPITAL

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CHILDREN’S HOSPITALS

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Level 20 332’ - 2” Level 19 317’ - 2” Level 18 302’ - 2” Level 17 287’ - 2” Level 16 272’ - 2” Level 15 257’ - 2” Level 14 242’ - 2” Level 12 227’ - 2” Level 11 210’ - 2”

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ANN & ROBERT H. LURIE CHILDREN’S HOSPITAL

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Ground floor plan

Façade | View of building in its surroundings | The extensive park | Internal street

Royal Children’s Hospital

Architect

Billard Leece Partnership; Bates Smart

Client

Government of Victoria

Completion

2011 (phase 1), 2015 (phase 2)

Floor area

165,000 m2

Capacity

334 beds

Melbourne, Australia

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Nature is the overriding theme in the design of Royal Children’s Hospital. It replaced an existing facility adjacent to it. The old building, a factorylike, clinical structure that did little to make children feel at ease, represented all the characteristics the designers wanted to avoid; after its demolition, the site became part of Royal Park. Aiming at an integrated park-hospital system, Ron Billard, author of the masterplan, conceived the building as intimately linked to this green oasis. The design philosophy reflects some of the major principles of evidence-based design, notably the view that nature has well-documented beneficial effects on health (ranging from

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First floor plan

lower heart rates to a higher sense of well-being). These effects supposedly date back to prehistoric times, when our ancestors preferred places that offered a view onto their surroundings, such as the savannah, the first landscape inhabited by human beings: open fields sparsely dotted with groups of trees. Plants signaled the availability of food, allegedly the reason they still generate positive feelings. What developed in ancient times as essential for the preservation of the species was never completely lost and still guides our fundamental reactions. Royal Park has been designed in a way that resembles this type of open landscape. The wings of the hospital invade

the park, which in turn penetrates the building. Five strategies were defined to enhance the green qualities within the building, some of them using sophisticated technology to mimic nature. The first technique involves the provision of images of nature rather than nature itself; it comprises artificial nature as well as formal references to natural phenomena. These include soundscapes (broadcasting the sound of falling water or the singing of birds), family seating in the form of coral branches and a cylindrical aquarium more than 7 m high, that also acts as a landmark in the wayfinding system. Passive interaction, the second strategy, is made possible by the visual

connections provided from the windows (enhanced by designing the top of the window frames as mirrors that allow children who cannot leave their beds to see the park outdoors), viewing platforms and the introduction of plants and greenery from the park inside the building. Nature can also promote social interaction, inviting people to share the sensation of enjoying natural scenes in each other’s company – the third objective. The fourth strategy incites children as well as their company to engage in physical exercise. This calls for the design of circuits and trajectories that are appealing; soundscapes are used to highlight the experience

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Section

of walking around. Finally, direct contact with nature is fostered by the overall layout of the hospital, which gives access to the park via a landscaped playground. The emphasis on natural features in architecture is promoted by the Green Building Council of Australia, which issues so-called ‘green star’ tools that strive to minimize the impact of construction on the environment. In the realm of healthcare the use of greenery can increase staff productivity and improve health recovery; moreover, the principles of ‘eco-design’ can result in substantially lower costs. 75 % of the roof, for instance, is used to harvest water, and the hospital has its own biomass plant.

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The implantation of a large-scale structure like this in a park is no easy task. By making full use of a slope on one side of the plot, roads in the immediate vicinity of the complex could be avoided, allowing a connection between building and park on three levels. Core of the layout is a six-storied spine of 100 m that links the main entrance with a landscaped garden. A sky garden enlivens this central spine. Designed by Buro North, the signage system is partly based on landmarks, among them the aquarium and a sculpture by Alexander Knox, called ‘Creature’. Narrow footprints ensure that daylight pervades most parts of the building. The patient wards are

closest to the park, allowing children to benefit from the natural surroundings. Although the hospital receives 240,000 patients each year, who are usually accompanied by their parents, the overall atmosphere is one of calm. References to eight types of Victorian landscapes can be found and the planting scheme results in an open scenery that corresponds to the park outside. There are 85 % single bedrooms, providing space for parents as well and thus embracing the philosophy of family-centered care. The side facing the city is marked by the use of sun protection shields that look like leaves in a great variety of natural colors.

Internal street and foyer | The ‘Creature’, sculpture by Alexander Knox | Inpatient unit | Lecture theater | Inpatient unit with view to the outside | Emergency department | Staff station of day oncology

ROYAL CHILDREN'S HOSPITAL

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University Hospitals

University (or teaching) hospitals are geared to the needs of research and education. While they are often comparable to general hospitals in their departmental structure and services, they usually have more extensive diagnostic and therapeutic equipment. Due to their educational role, the spatial program includes study areas, lecture theaters, demonstration areas and (research) laboratories. Typologically, the teaching facilities are comparable to those in all other educational institutions, and the healthcare delivery facilities to those in other hospitals. Historically, university hospitals were equipped with operating theaters where students could observe and learn the surgical trade; only in the second half of the 20th century did it become common practice to use cameras and screens to limit the number of students in the operating room. With increasing specialization in medicine, the number of university medical centers increased as well, posing the problem of an overly specialized medical education. Recently, the interaction between clinical and theoretical studies has intensified, leading to an emphasis on translational research and intensive contacts between researchers and the medical personnel working in healthcare delivery. Today many university hospitals face the consequences of decades of unplanned growth on large sites in the urban periphery. Further expansion – often necessitated by the introduction of new technology – is usually impossible due to lack of space. This results in a process of optimization and intensification in the use of space, which must be planned carefully in order to preserve the clarity and cohesion of the original plan. One must bear in mind that the redesign and reconstruction processes of hospitals at this large scale resemble urban planning projects, drawing on the repertoire of urbanism such as streets, squares, parks or continuous open spaces.

Site plan

Center for Surgical Medicine, University Hospital Düsseldorf

Architect Client

Heinle, Wischer und Partner University Hospital Düsseldorf

Completion

2011

Floor area

20,631 m2

Capacity

316 beds

Düsseldorf, Germany

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In the 1960s and 1970s, decades of unparalleled economic and demographic growth in Western Europe and the United States, numerous hospitals were built. Not only did they increase in number, their size also tended to grow. University hospitals especially developed into vast complexes, reflecting the ever-growing demand for doctors needed to staff the new facilities. As medical specializations multiplied and branched off, additional spaces were required to accommodate them. The University Hospital Düsseldorf is no exception. It sits on a vast terrain in the outskirts of the city and is made up of a number of large, separate buildings connected by a network of

Sections

Glazed connecting bridge to the existing buildings | Main entrance with pedestrian access to the new building | Building four: patient rooms with balconies and large windows | Operating room with daylight

streets that has no inner logic and is entirely determined by the need to disclose the multitude of medical departments, the entrances of which do not respect the design of the public spaces between them, simply because design at this level is virtually non-existent. The new building combines surgery, neurosurgery, dermatology, and ophthalmology, replacing the facilities that housed these departments before. Characteristic of the building by Heinle, Wischer und Partner is its urban quality and the attempt to improve the overall organization of the complex by creating a new and clear traffic structure that, moreover, invites people to walk. The new clinic

is situated in the center of the terrain and intended as its central hub. Located in a rectangular building of two layers that combines the diagnostic and treatment areas, an elongated central passageway dubbed ‘Magistrale’ runs from north to south through the entire facility, connecting the three inner patios as well as the various clinics and the outpatient facilities on the first floor. Occupying the full height of this volume on the eastside, it is separated from the outside world by a glazed façade that floods it with daylight. A cafeteria, a space for contemplation and a kiosk offer patients, visitors and staff some diversion.

The ground floor of the southern part of the building is reserved for the emergency department; the helipad on top of the building has direct access to this department, and the entrance for ambulances is situated next to it. Nearby is the intensive care unit with fast connections to the surgery department as well as to the spaces for Röntgen imaging. Reminiscent of the classical hospital typology of the matchbox-on-a-muffin, better known as Breitfuß, the patient wards are located on top of the diagnosis and treatment areas in the low-rise, flat building below. Instead of one very high volume, four bars are situated on top of it, cantilevering several meters out of

CENTER FOR SURGICAL MEDICINE

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the Magistrale and the façade on the opposite side. Two of these bars have two stories, the other three. The floors of the four bars project outwards, the white, horizontal bands producing the building’s characteristic visual qualities. The wards are designed according to the double corridor model: rooms face either south or north; the space between the two corridors accommodates storage, nursing stations and services. Every nursing station is subdivided in two clusters of 16 beds in rooms with two beds each; apart from that, a limited number of single bedrooms has been included. In the bar volumes with three floors, the lower one accommodates the specialist

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Fifth floor plan

outpatient departments of the dermatology clinic and spaces for physical therapy, respectively. Sustainability is an important aspect of the design. The building uses geothermal energy, and the low-rise volume has a green roof. A leading design criterion was the abundant provision of daylight. The glass wall of the Magistrale guarantees that it penetrates the building from this side, the patios provide it from within, and the operating rooms have daylight as well. For the transportation of all kinds of materials, a separate traffic circuit with automated carts has been provided.

Detail of first floor plan: ICU

Detail of first floor plan: operating rooms

CENTER FOR SURGICAL MEDICINE

191

The Knowledge Centre St. Olavs Hospital, Trondheim Norway

PRINCIPAL SECTION

SITUATION PLAN

Site plan (Knowledge Center shown in green)

St. Olav’s Hospital

Architects

Nordic – Office of Architecture; Ratio Arkitekter

Trondheim, Norway Client

Helsebygg Midt-Norge

Completion

2013

Floor area

223,000 m2 (women and children’s center 28,000 m2; AHL 40,000 m2; Knowledge Center 18,000 m2)

Capacity

192

UNIVERSITY HOSPITALS

834 beds

This university hospital introduced a novelty in Norwegian healthcare architecture: it was the first to integrate treatment, research and teaching. Built in three phases, it opened in 2005 (phase 1), 2010 (phase 2) and 2013 (phase 3). This complex project replaced an existing facility that had to be kept operational during construction work. 85 % of the existing building stock has been demolished, but parts of the original hospital of 1902 were retained. The first phase comprised a laboratory center, a women and children’s center, a center for neurotherapy, the first part of a supply center, the technical infrastructure and the patient hotel. These were

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Ground floor plan Knowledge Center

South façade of the Knowledge Center | Evening view on the terrace and patio of the heart and lung center | Heart and lung center by night

realized between 2002 and 2005; the term ‘patient hotel’ reflects the strategy to design most of the new complex as generic elements, a strategy with advantages from a real estate point of view as well as an approach that helps to prevent the typical hospital atmosphere with its overwhelmingly negative associations. The projects of the second phase were completed in 2010. By then, the AHL (accident and emergency center combined with a heart and lung center), the mobility center, the abdominal center and the final part of the supply center had been added. The Knowledge Center was completed in 2013 and houses the hospital’s auditoriums, the main

library, facilities for teaching and research as well as a clinical section. The architects created a small city-in-a-city. Located in the center of Trondheim, a thriving town on Norway’s Atlantic coast, the plan had to respect the grid structure of relatively dense blocks on which it is projected. St. Olav’s has been conceived as a medical district, a distinct zone that nevertheless partakes in urban life. During the design phase, the notion of patientcentered care has been substantiated by involving future users – both staff and patients – in an ‘inclusive design’ process.

The division in a series of generic small-scale building clusters, each representing a clinical center, is a key feature. These centers of up to four stories are arranged around open, green squares. Flexibility is ensured as a center can vary in size over time from the scale of a single building block to an entire cluster of buildings or parts of it. The spatial organization of the blocks serves to minimize walking distances of the staff and the need to move patients around. Tunnels and suspended, glazed corridors connect the blocks; the latter offer unique views of the Trondheim landscape. The basement is reserved for logistics and technical supply purposes, the

ST. OLAV’S HOSPITAL

193

Corridor in the Knowledge Center | Waiting area in the women and children’s center | South façade of Knowledge Center with screens open

ground floor concentrates the hospital’s public functions, located on the first floor. The hot floor occupies the second floor while the third floor accommodates technical functions. Above, the fourth, fifth and sixth floors are reserved for the clinic; the patient wards offer views to the city and the landscape. The green courtyards provide an ideal setting for patients and staff to enjoy a landscaped, natural and intimate environment. For recovering patients, these green spaces function as a first step to the outside world. Aware of the crucial emotional psychophysical impact of nature, the landscape architects offer outdoor experiences in three stages, correspond-

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UNIVERSITY HOSPITALS

ing to the range and needs of the hospital’s users. 25Æ% of the ground floor of the centers is saturated with greenery that fosters a natural experience. The outdoor public space, blurring the borders between the hospital and its environment, incites a more active use; it is enhanced by artwork and local plant species and connects with the natural reserve of the Nidelva River. On the other side, St. Olav’s public spaces gradually merge with the historical part of Trondheim, dominated by its majestic Nidaros Cathedral and vibrant daily life. Giuseppe Lacanna

?

South 01.10.2012

Anne Aanerud +47 97 97 24 85

Elevation Knowledge Center

Floor plan AHL

Foyer in the laboratory department

ST. OLAV’S HOSPITAL

195

East elevation

Site plan

Cross section showing courtyard and internal street

View of the west façade with treatment buildings and emergencies entrance in front building | Night view of the complex with front building | The main entrance with the wide, cantilevered canopy | The gables of the inpatient wards accommodate sheltered outdoor spaces for patients and staff

Akershus University Hospital Oslo, Norway

196

UNIVERSITY HOSPITALS

Architect

C. F. Møller Architects

Client

Helse Sør-Øst RHF

Completion

2014

Floor area

118,000 m2

Capacity

565 beds

In 2009, the design for Akershus University Hospital won C. F. Møller Architects the prestigious Building Better Healthcare Award. This prize-winning building is inspired by several of the innovative ambitions that began to pervade healthcare architecture in the 1990s: the wish to offer patients and staff a non-institutional, informal environment, the focus on patients rather than on medical processes and the awareness that the patients’ experiences while staying in a hospital should not isolate them from everyday life outside. The architects decided against the use of design strategies that would hide the impressive size of this building.

South elevation

Longitudinal section showing internal street

Instead, they borrowed a theme from urbanism and opted for a configuration of volumes connected via a five story high, glass-covered central spine leading from the entrance, which faces south, to the children’s ward that terminates the main axis in the north. Most of the beds are accommodated in four ‘fingers’ that stretch out from the spinal cord. The patient wards have single and double bedrooms alternated with social spaces (squares) at every five rooms. Nurse stations are at the center of each ward. They have a balcony that provides them with natural daylight. All rooms have views

on the park, the forest, and the mountains in the distance. To allow children to enjoy direct contact with the outside world as well, extra windows have been made beneath and also above the regular ones. Flatscreens with internet access have an integrated control panel that gives patients the possibility to adjust temperature and lighting. Since all outpatient departments are located on the central spine at the ground floor, the traffic their visitors usually produce is kept out of the rest of the building and concentrated in the main interior circulation artery, where it produces an almost urban atmosphere. Niches along the central street have been

designed to act as waiting spaces. This arrangement implied the need to move the emergency department to the first floor. The hot floor has been arranged around four courtyards on the other side of the central artery. Teaching facilities are dispersed throughout the entire building, thus enhancing the interaction between students and hospital, and preventing separating the students from the medical working environment. The combination of fingers and courtyards guarantees an abundance of daylight, one of the qualities recognized by Evidence-based Design as being beneficial for patients and staff alike.

AKERSHUS UNIVERSITY HOSPITAL

197

View of glazed internal street | Façade detail | Wood and natural stone are the dominating materials of the internal street | Exterior view of the complex and front building, artwork by Tony Cragg | Canteen

Moreover, it provides visual connections to the landscape that prevent the impression of being detained in a hermetically closed environment. Similar to cities that have grown organically, the complex shows a variety of components characterized by slightly different materials and colors, which nevertheless are clearly part of the larger whole. Here, this effect is enhanced by the use of panels in wood, aluminum, white-lacquered sinusoidal aluminum, tombak and glass within a color scheme derived from the panels designed by the Icelandic artist Birgir Andrésson. The patient wards are clad in black, the children’s department in oak panels; in the central spine

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wood dominates. Within the wings of the building, the same strategy is used to single out smaller parts of different functions. The central spine has been designed as a public boulevard with facilities ranging from a church to a hairdresser; secondary, semi-public streets branch off from this boulevard to the treatment areas to the left and the patient wards to the right of the entrance hall. The artwork complements the overall clarity of the layout to facilitate wayfinding, a crucial element for preventing patients and visitors from getting – or feeling – lost. Moreover, the personnel staffing the

reception desks in the main thoroughfare are there to help, adding a human touch. One of the hospital’s explicit goals was to gradually reduce unsustainable technologies, particularly the reliance on fossil energy. Ground heat is processed in a geothermal power plant that caters for 40 % of the building’s total energy consumption and is one of the largest of its kind in Europe.

Fifth floor plan

Ground floor plan

AKERSHUS UNIVERSITY HOSPITAL

199

Site plan

Main building with patient wards, perspective from a

LAGEPLAN 1/10000

corridor between the clinics | View across the Main River | Entrance

Reconstruction of the Johann Wolfgang Goethe University Hospital Frankfurt am Main, Germany

200

UNIVERSITY HOSPITALS

Architect

Nickl & Partner Architekten

Client

Hessian Construction Management for the State of Hessen

Completion

2014

Floor area

197,460 m2

Capacity

466 beds

Only about 6 % of the investments in healthcare facilities in Germany are channeled toward the construction of new buildings – the majority of projects are renovations of the existing building stock such as the Universitätsklinikum Frankfurt. Built in the late 19th century on the outskirts of the city, the original pavilion hospital with its lavish gardens was largely destroyed during the Second World War. In the 1960s, a new central building designed by Godehard Schwethelm and Walter Schlempp as a ‘matchbox-on-a-muffin’, or Breitfuß, was erected. Since the facility was outdated, a renovation of the vertical slab with the patient wards and a total refurbishment of the

KLINIK FÜR ALLGEMEINCHIRURGIE

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INFEKTIOLOGIE Allgemeinpflege 16 Betten

Ground floor plan

three-storied pedestal from which it emerges was conducted over 15 years. The first phase expanded the north-south axis that runs perpendicular to the high-rise slab and pierces through it on the eastside. One of the two major traffic arteries, it separates the main part of the ‘muffin’ from a newly added wing to the east of it. This so-called ‘Magistrale’ is marked by a stretched roof on stilts that leads to a large, glazed hall; the roof that covers the exterior part of the Magistrale, which leads to the river Main, creates a spatial and visual counterweight to the high-rise volume, resulting in a balanced architectural composition. Then three existing buildings connected to the

‘muffin’ on its norther edge were renovated; they are used for research and teaching purposes. In 2012 the renovation of the vertical slab with patient wards was completed and the revitalization of the low-rise building on which it sits began. This part accommodates the second traffic artery that cuts through the entire complex from east to west. Providing the clinic with a second life, the architects succeeded in highlighting the architectural qualities of the 1960s slab. Whereas the redesign of the high-rise building focused on the façade, the renovation of the base resulted in an almost

completely new building. Apart from the structural grid of 7.20 m, little of the original structure remained. The new infill houses the department of conservative medicine and laboratories for endoscopy as well as a new central auditorium, but most striking is a spacious entrance hall that is ushered in by a stretched roof and forms part of the Magistrale, connecting the research and educational facilities of the university with the hospital. In their design competition entry, the architects proposed to reconstruct the hospital as a composition of urban spaces. Their masterplan involved

RECONSTRUCTION OF THE JOHANN WOLFGANG GOETHE UNIVERSITY HOSPITAL

201

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First floor plan

Lobby with artwork | Generous staircase and lobby space

an internal traffic scheme that, apart from the two main axes, envisaged main streets, secondary roads and squares, connecting the different departments in the podium building with the open, elongated patios introduced here. Daylighting, parquet flooring and wooden reception desks create a homely, warm and comforting atmosphere.

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Fourth floor plan

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Third floor plan

ZENTRAL - OP

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Second floor plan

RECONSTRUCTION OF THE JOHANN WOLFGANG GOETHE UNIVERSITY HOSPITAL

203

Main traffic structure Sluice Radiotherapy Reserve Services Shared spaces Lab oratories and pharmacy Emerg ency department Technical spaces Shaft

Ground floor plan

Erasmus MC Hospital and Education Center Rotterdam, the Netherlands

Architect

EGM architects; KAAN Architecten (Education Center)

Client

Erasmus MC

Completion

2017 (2013 Education Center)

Floor area

207,000 m2 (34,000 m2 Education Center)

Capacity

522 MC beds, 56 ICU beds, 94 places for daycare treatment

204

UNIVERSITY HOSPITALS

The new Erasmus MC Hospital, short for Erasmus University Medical Center, is the result of a refurbishment project. Erasmus MC is the second largest hospital in the Netherlands (1,320 beds altogether) and also a teaching hospital, affiliated with the Erasmus University. Its existing facilities, originally designed in the 1960s by Dutch architect Arie Hagoort of Delft office OD205 in collaboration with Jean Prouvé, no longer met today’s requirements and were too small. Therefore, part of the original building stock was replaced by a medical city that represents the state of the art of today’s hospital planning. One of the buildings that will be

Main traffic structure Staff Outpatient department Reserve Services Shared spaces Shaft

First floor plan

View from Museumpark | Aerial view of entire campus (rendering): the new Erasmus MC is the L-shaped structure to the right of the tower, the Education Center is located left of the tower | Connecting bridge | Logistic corridor at ground floor level

demolished is the original, slab-like Dijkzigt Ziekenhuis designed by Aad Viergever. Opened in 1961, it introduced the double corridor model in the Netherlands. Due to the constraints of the tight inner city site, refurbishment was not feasible – despite its architectural achievement. After Dijkzigt got promoted to a university hospital in the 1960s, it merged with the Daniel den Hoed Cancer Institute, new buildings were added and it was renamed Erasmus University Medical Center. The white faculty building by Jean Prouvé, for a time the highest building in the city, is its most remarkable feature. The tower represented the zone dedicated to research and

education; the hospital was extended in 1993 when OD205 added Erasmus MC Sophia Children’s Hospital, which was completed in 2007 by a Ronald McDonald house designed by EGM architects. EGM architects added one story to the children’s hospital and refurbished it. The existing faculty buildings, including the tower and the two-storied parking deck underneath, the children’s hospital and the 2013 Education Center were to be integrated in the new masterplan. The general composition of the new building is strikingly simple: a U-shaped, long-stretched interior street (shown in yellow

in the floor plan) – a covered boulevard – serves as the hospital’s public backbone; it is located at the first floor (connecting with the refurbished parking deck that has become the core of the ‘drive-in’ hospital). The covered boulevard connects the existing building with several entrances in the new hospital. This backbone guides patients, visitors, students and staff members to the hospital buildings and the buildings for research and education – a zone that is crowned by the faculty tower (yet to be upgraded). EGM architects decided to add a second tower of 120 m and with 31 stories near the existing one; it contains mainly offices and

ERASMUS MC HOSPITAL AND EDUCATION CENTER

205

Main square, a public space on former ambulance deck for Sophia Children’s Hospital | Waiting area in emergency department | Trauma room in emergency department | View of tower through glazed internal boulevard

is designed as a generic office tower. The new hospital wing has been built perpendicular to the research and teaching zone. It is divided into visual units appearing like a row of individual buildings lining a street. One of the interesting (semi-)public spaces that is adjacent to the new hospital building is the Education Center by KAAN Architecten, to the left of the tower in the aerial view. It forms the central hub of all educational programs of the teaching hospital, combining lecture rooms, the medical library and a variety of cubicles that accommodate groups of students. This new

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facility occupies a former courtyard on top of a car park which was repurposed and roofed over. The core of the center is a spacious three-story atrium with parquet flooring and a 35 m high bookshelf; wood is also used to clad the exterior of the cubicles, contrasting with the bright, white tones of the furniture, the walls and the trusses that span the covered square. They form the building’s most spectacular architectural feature: the roof is the result of the playful application of white beams with squares that are subdivided in four smaller squares. These, in turn, are filled in with triangular lightwells, flooding the square with soft, filtered light.

The new Erasmus MC is guided by patient-centered care, as is demonstrated by the subdivision in clusters, the single bedrooms and design features that enhance positive patient experience: abundant greenery inside and outside, views to two parks (and an accessible roof garden in view of the clinical wards), the use of well-designed street furniture in the main traffic arteries and a clear zoning structure that distinguishes the teaching facilities from the hospital, providing spatial and visual links that promote translational cooperation.

Second floor plan

Views of library with lattice ceiling | Triple-height space with bookcase

ERASMUS MC HOSPITAL AND EDUCATION CENTER

207

Specialized Hospitals

Specialized hospitals or clinics are characterized by the specialist medical care they provide. The more the level of specialization increases, the higher the number of specialized hospitals. Typologically, these hospitals largely resemble general hospitals. There is also some overlap with rehabilitation clinics or geriatric facilities.145 Obviously, specialization and scale are key to achieving the most advanced level of medical performance. Often, there is an emphasis on expensive and complex technology in these clinics. Typical institutions of this type include trauma centers, ophthalmological centers, heart clinics, orthopedic hospitals, mother-andchild centers and cancer centers. Because of their specialty, these institutes usually have a supra-regional role, as opposed to general hospitals that cater to a local population. Cancer treatment, which increasingly relies on advanced technology, expensive facilities and multidisciplinary cooperation, is one of the first areas for which specialized hospitals were built. Heart clinics, which usually cover the entire range of cardiothoracic and vascular diseases, are also increasingly leaving the general hospital setting, and are being organized as specialized institutions operating at a supra-regional or national (rather than a local) scale. Recent additions include institutes for genetic disorders and, particularly in countries with an aging population, aging clinics. The latest generation fosters intensive, translational cooperation between clinicians and scientists; architecture facilitates this interaction.

GEHRY PA RT NERS, LLP. A RCHIT ECT

WSP CA NT OR SEINUK

Ground floor plan

ST RUCT URA L

PROPERT Y LINE

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DENEEN POWELL A T ELIER, INC.

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ENGINEERS, PLA NNERS, SURV EYORS

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Exterior view with entrance and landscaping | General view | Interior view | Ceiling | Main lobby | Outdoor seating area | Entrance

Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, Nevada, USA

Architect

Frank Gehry

Client

Keep Memory Alive

Completion

2010

Floor area

6,000 m2

Capacity

13 examination rooms, 400-seat auditorium

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SPECIALIZED HOSPITALS

Brains can play strange tricks on people; sometimes we see things that do not exist or believe them to be different than they actually are. Passersby who see the Cleveland Clinic Lou Ruvo Center for Brain Health and adjoining Keep Memory Alive Event Center may wonder if what they see is real – a building that looks like a mirage. Its undulating walls are pierced by 199 windows – not a single one alike. Keep Memory Alive (KMA) was founded in 1996 by Larry Ruvo in honor of his father, Lou, who passed away from Alzheimer’s disease. KMA serves as the fundraising arm for the Center and

GEHRY PA RT NERS, LLP. A RCHIT ECT

WSP CA NT OR SEINUK

First floor plan ST RUCT URA L

PROPERT Y LINE

COSENT INI A SSOCIA T ES

MECHA NICA L, ELECT RICA L, PLUMB ING, FIRE PROT ECT ION & I.T .

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T RA NSSOLA R

CLIMA T E ENGINEER

DENEEN POWELL A T ELIER, INC. LA NDSCA PE A RCHIT ECT

G.C. WA LLA CE, INC.

ENGINEERS, PLA NNERS, SURV EYORS

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B UILDING MA INT ENA NCE

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aims to raise awareness for Alzheimer’s and other neurocognitive disorders. In 2009, KMA partnered with Cleveland Clinic to create Cleveland Clinic Lou Ruvo Center for Brain Health. The Center is comprised of a clinic with 13 examination rooms, offices for health care practitioners and researchers, a so-called ‘Museum of the Mind’ and an events center that seats 400 people. Its one-of-a-kind architecture enhances the Center’s name recognition and acts as an ideal marketing tool. The building’s peculiar shape was strategically designed to stand out and generate attention. The events center is rented out for a variety

of events including weddings, dinners, conventions and meetings with 100 % of the proceeds benefitting Keep Memory Alive. By now, it has become an important charity initiative in Las Vegas and a key participant in the nation’s fight against Alzheimer’s disease. Constructing the Center was as exciting as its design. The 18,000 unique stainless steel shingles making up the façade needed to be recognizable for the engineers during construction. Barcoding each sheet allowed the German engineering team to keep track of each individual piece and compare its relationship to adjacent pieces in

A 2- 1.2

order to determine if adjustments were needed. In total, 65,000 hours were spent in engineering and three years, three months and 13 days were needed to complete this extraordinary architectural landmark. Two continents, one body of water and one desert were covered during the transportation of the prefabricated materials shipped from China to Las Vegas. The Center is a popular downtown Las Vegas destination that serves as a symbol of hope.

CLEVELAND CLINIC LOU RUVO CENTER FOR BRAIN HEALTH

211

East-west section

Surgical Clinic of La Croix-Rousse

Architect

Atelier Christian de Portzamparc

Client

Hospices Civils de Lyon (HCL)

Completion

2010

Floor area

46,000 m2

Capacity

214 beds

Lyon, France

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SPECIALIZED HOSPITALS

Situated next to a historical hospital building on a terrace overlooking the city, this surgical clinic is Christian de Portzamparc’s first venture in healthcare architecture. The client preferred this renowned designer to specialized firms, expecting him to rethink the relation between hospital and city. By referring to the historical building and making optimum use of subterranean spaces, the six-floor building remains inobtrusive, despite its considerable length. De Portzamparc created a large rectangular volume that continues the building line of the old hospital, respects its height and repeats the rhythm of its windows, thus creating a present-day interpretation of the

West-east section

View across the square in front of the building, with access to the underground parking area | View of pavilion from the north; a bridge provides a connection to the biological laboratory | View of terrace leading up to main entrance

listed monument. The design strategy to engage in a dialog with the historical structure and the old city resulted in radical solutions for a major challenge: the new volume, roughly the size of the existing hospital, could not possibly accommodate all the functions the program required. Therefore, de Portzamparc needed to create more space. Underneath the terrace in front of the building, he added three floors; by piercing several lightwells through the terrace floor, he made sure the departments underneath received additional daylight. The lower levels are used as parking garage. Bridging the distance between historical setting and contemporary life,

he then added a shiny, glazed square volume that looks rather self-contained but is clearly part of the new ensemble. A large entrance hall with bay windows and a spacious and light interior creates a soothing, reassuring atmosphere. Whereas the side of the building overlooking the terrace refers to the old hospital, the back façade resembles an apple with a few bites taken out. An elegantly curved wall clad in gray stone envelopes three wings that radiate outward from the main building; the far ends of two of these wings coincide with this outer skin. The other façades are plastered and painted in bright colors; the windows have been designed as

sculptural elements. The surgical clinic for La Croix-Rousse has a clear layout. Apart from the main entrance, the ground floor also houses the consultation rooms and the day hospital. Technologically, the first floor is the heart of the building. Here we find 15 operating theaters, the recovery department with 50 beds, nine rooms for endoscopic research and spaces for radio therapy. Critical and intensive care is on the second floor; the three stories on top of that accommodate the patient wards. The single bedrooms have a multimedia unit attached to a flexible arm that is mounted on the bed.

SURGICAL CLINIC OF LA CROIX-ROUSSE

213

East elevation

0

Sculptural windows and bow windows enliven the façade of the back of the building with the patient rooms | The slick façade of the aluminium-clad pavilion and the rough material of the base create a stark contrast | Views of the public spaces near the entrance

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SPECIALIZED HOSPITALS

5

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5 Entrance emergencies 6 Intensive care rooms 7 Emergency sluice 8 Imaging department 9 Biological laboratory

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Ground floor plan (lower level)

SURGICAL CLINIC OF LA CROIX-ROUSSE

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Site plan

Milstein Family Heart Center NewYork-Presbyterian Hospital

Architect

Pei Cobb Freed & Partners with da Silva Architects

Client

NewYork-Presbyterian Hospital

Completion

2010

Floor area

11,600 m2 (new construc-

New York, New York, USA

tion); 3,700m2 (renovation) Capacity

20 beds (intensive care unit), 25 beds (ambulatory surgery center)

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SPECIALIZED HOSPITALS

One of the best known high-rise hospitals, NewYork-Presbyterian Hospital marked new ways of thinking in healthcare architecture in the 1920s. Located on the Hudson, it ushered in the golden years of skyscraper hospitals. Numerous buildings were added to it in subsequent years, culminating in a majestic symbol of modern healthcare. Over time, however, part of the building stock was in need of refurbishment if the hospital wanted to live up to its standards as a state-of-the-art institution. For the Milstein Hospital, which opened in 1989, an extension became necessary as the clinic, with over 100 operations each day in 26 operating theaters,

Section AA

View from Hudson River | View from Riverside Drive | General entrance | Exterior view with George Washington Bridge | Climate façade detail

had become one of the most sought after heart surgery centers in the USA. Next to the clinic, squeezed between its main building and the Herbert Irving Pavilion, a piece of land had been left untouched, a chunk of solid rock making construction difficult and expensive. Now the need to expand the clinic made it imperative to overcome these difficulties. The architects faced the task to provide the extension with a distinct character. They did so by introducing curved façades that contrast with the rectilinear lines of the adjacent Herbert Irving Pavilion. Overlooking the Hudson River,

the new wing of the Vivian and Seymour Milstein Family Heart Center (as its full name is) provides impressive views. In the public areas, curved lines mark the transition between the original center and the new addition. This gives the extension a character of its own and connects it graciously to the existing building. The transition zone between the old and the new building culminates in a large atrium that gives access to the waiting areas and the prefunction spaces facing the glass façade. It can be reached via the lobby of the existing building or via its own entrance from a side street. Bridges across the four story high atrium facilitate the interaction

between the old and new wings. Laboratories and medical imaging are located on the basement level, and the ground floor accommodates a conference center with a prefunction space, an auditorium and meeting rooms. The second floor is reserved for the invasive cardiology suite, with 11 cardiac cath labs. The third floor houses the ambulatory surgery center, consisting of eight operating theaters: two are outfitted for stereotactic surgery, four for minimal-access surgery and two for general surgery. Diagnostic facilities and echocardiography are on the fourth floor, and 20 intensive care units on the fifth.

MILSTEIN FAMILY HEART CENTER

217

Waiting area with view toward the river | Lobby | Atrium interior with climate façade | Consultancy rooms | Operating theater

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SPECIALIZED HOSPITALS

First floor plan

Ground floor plan

MILSTEIN FAMILY HEART CENTER

219

Site plan

View from sunken courtyard | Overall view from north

National Center for Tumor Diseases Heidelberg, Germany

220

SPECIALIZED HOSPITALS

Architect

Behnisch Architekten

Client

Deutsche Krebshilfe e. V.

Completion

2010

Floor area

13,120 m2

Capacity

60 beds (day hospital)

The National Center for Tumor Diseases in Heidelberg is an institution for research on the genetic causes of cancer. This research involves intense multidisciplinary interaction, relying on translational ways of working and thus narrowing the gap between research and the treatment of patients. It is located on a campus with other medical facilities and the university hospital. The Center mediates between the architecture of the adjacent ear, nose and throat clinic with its straight lines and perpendicular grid, and the sculptural qualities of the children’s hospital on the opposite side. The two lower levels combine a rectangular volume and a part that tapers toward

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View from north with patient garden | Retreat room ‘Raum der Stille’ in atrium

the children’s clinic. Clad in green glass, the two segments create a single volume that carries a boomerang-shaped white volume set on top of it. This superimposed structure cantilevers outward above the main entrance and its façade is pierced with recessed windows set at irregular intervals. A basement with a garden completes the overall composition. Centerpiece of the building is a large four-story hall covered with a prismatic roof. This heart of the building gives access to all departments. The atrium, evoking the liveliness of an urban square, encourages people to walk around.

The two lower levels accommodate the outpatient areas and on each floor a day hospital. Consultancy areas have been designed as lounges. Furnished with chairs designed by the architects, they can be used by three to five patients each. At the ground floor, gardens have been added that are accessible only from the inside; on the first floor; balconies serve the same purpose. A meditation room (‘Raum der Stille’, or silent room) provides space for contemplation. Designed as a womb-like shell, it receives daylight from a lightwell on top. The part of the building facing the ear, nose and throat clinic contains the laboratories and, separated from it by a glass

wall, a documentation center for multidisciplinary teams that is subdivided in small units for six staff members each. The white boomerang on top accommodates two floors of conference facilities and spaces for scientific research as well as the rooms for the Center’s administrative board. Although the scale of the Center is modest, easy wayfinding was essential. Behnisch Architekten designed robust square graphics as a basic common feature of the entire signage system; wherever useful, lettering on the doors to the various departments was added.

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Ambulance reception | Cafeteria | Laboratory | Therapy chair for oncological day hospital | Patient corridor

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Reflections of the façade | View from Rue du ChercheMidi | Façade details

Institut Imagine

Architect

Ateliers Jean Nouvel; Valero Gadan Architectes

Paris, France Client

Institut Imagine, AP-HP Assistance PubliqueHôpitaux de Paris

Completion

2014

Floor area

19,000 m2

Capacity

400 workplaces, 250-seat auditorium

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At the corner of the Boulevard Montparnasse and the Rue du Cherche-Midi, Jean Nouvel and Bernard Valero designed a state-of-the-art genetic imaging center. Genetic disorders account for 5,000 severe diseases; in Europe alone, they affect 35 million people. Joining forces with private companies and charitable foundations, the state, the city, a university and a hospital teamed up to create this institute. As is often the case with highly specialized facilities offering services for a cross section of patients, the institute is built in close proximity to a hospital, in this case the Hôpital Necker-Enfants Malades. Institut Imagine itself is dedicated to research; patients

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do not stay there overnight. The children, often accompanied by their parents, enter the building from the side of the hospital and find the clinics on the ground floor. The institute’s research laboratories facilitate close translational cooperation of some 400 experts of different fields who have several technology centers at their disposal for all forms of genetic analysis, cell and molecular imaging, gene transfer procedures as well as a DNA data center. On the first floor, a conference center has been included with an auditorium that seats 250 people. The clinic includes consultancy rooms, facilities for clinical research, a center for biological resources and 11 specialized units

for rare diseases. Views on the interior garden establish visual contact between the researchers and the children visiting the clinic. Social spaces, often in patios, stimulate interaction between them, the clinicians and the patients – the institute’s so-called ‘golden triangle’. The design of Institut Imagine presents a contemporary reinterpretation of some of the qualities of historic Parisian hospital architecture, especially the availability of ample greenery and the transparency of earlier hospital sites that allow for strolling around. Institut Imagine wants to be transparent, offering views across the site and

inviting patients and parents to enjoy the building’s public spaces, notably the six story high grand hall carved with a light-flooded interior garden that is connected to the lobby on the side of Boulevard Montparnasse. Synergy is a key strategy in tracing the origin of genetic diseases, the institute’s core business. Research directly informs treatment strategies, which in turn generate questions that trigger further investigation. Architecture can stimulate this way of working by creating spaces for the casual encounters of scientists and clinicians, informal meetings having been identified as

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Skylight providing ample daylight | Waiting area | Atrium | Terrace and cafeteria | Laboratory

particularly useful. The research departments have been integrated in care clusters that target specific medical conditions, preventing their division in separate wings far away from the patients. Dedicated to medical imaging, the building expresses its function in the graphic treatment of the façades, where a repetition of characteristic DNA samples has been applied to the glass panels. Aspiring to make what the architect called ‘high-precision light architecture’, the center perfectly symbolizes its function.

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Site plan

Façade patterns (Graphic design: Atelier Hiroshi Maeda)

INSTITUT IMAGINE

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Section showing the five care villages

Cancer Centre at Guy’s

Architect

with Stantec Client

London, UK

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Rogers Stirk Harbour + Partners

Guy’s & St. Thomas’ NHS Foundation Trust

Completion

2016

Floor area

20,000 m2

The cancer treatment center concentrates most of the oncological departments formerly dispersed across 13 buildings on the two sites of the Guy’s & St. Thomas’ Hospital. The designers and Stantec – the healthcare specialists – developed a masterplan for these fragmented departments which facilitates multidisciplinary and translational ways of working. The site, a small, triangular plot, left the architects no other option but to design a tower, a building of 14 floors. In its densely built-up inner city setting, the center mediates between Renzo Piano’s 300Æm tall Shard, the medium-height tower wing of Guy’s and the lower urban fabric south of it. The building combines

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Sixth floor plan: Chemotherapy Village – main level

Exterior view from Crosby Row | Views of chemotherapy atrium | Outpatients' garden and balcony | ‘Welcome Village’ staircase and atrium

four stacked villages of two or three floors: a welcoming entrance cluster, radiotherapy (the first such department in Europe to be located above ground), an outpatient cluster and a department for chemotherapy. The northside of the tower concentrates the science and treatment zone with an emphasis on clinical procedures and technology; the southside is reserved for therapies with a social and interactive nature. The entrance hall of the building, a double-height, glazed lobby acts as a transition zone between the urbanity outside and the urbane atmosphere within. It is designed as a new gateway to the

hospital campus, accommodating a mix of different users and passersby. Patients and visitors arriving at the ‘Welcome Village’ may use the educational and complimentary therapy activities offered there or access the other three villages which represent stages in the cancer patient journey: radiotherapy, outpatients and chemotherapy. Each village has two or three floors and the outpatients’ department has facilities for imaging diagnostics and minor medical procedures to minimize patient travelling. Upon leaving the lift, patients enter a square with an external, planted balcony attached to it. The villages have smaller squares intended

to foster interaction between patients and caregivers, researchers and clinicians. These have been designed in a homely, domestic idiom, offering respite from the inevitably clinical atmosphere in the rest of the departments. The building incorporates work by five worldclass artists: Daniel Silver, Gitta Gschwendtner, Angela Bulloch, Karel Martens and Mariele Neudecker. Designer Ivan Harbour sees improving people’s lives as a responsibility for architects, and architecture as an effective tool to do so. Therefore, providing patient-centered care in a building with a human scale was one of the principal goals.

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Outpatient Clinics and Health Centers

If large-scale general hospitals and university medical centers, representing the advantages of concentration and scale, mark one end of the range of distribution models for healthcare facilities, small community-based outpatient clinics, operating either standalone or as a satellite in a network of facilities, mark the other end. Whereas standalone outpatient clinics are usually built by the hospital organizations that run them, community health centers, often consisting of general practitioners, pharmacies and usually several forms of physical and psychotherapy, in addition to hospital outpatient services, can also evolve from local, bottom-up initiatives. These small clinics can be seen as a test case of decentralized healthcare, though their viability is largely determined by the healthcare systems in which they operate. Only when they are part of healthcare networks, allowing them to refer patients with complex issues on to specialized clinics, are they able to take over a substantial part of everyday hospital services. Such a health center system is viable in regions with fairly high population densities where they complement high-end medical facilities; low-density areas lack the sufficient numbers of prospective patients required for a positive business case. One of the advantages of the small scale is patient-friendliness and the absence of the complexities inherent to larger institutions and the administrative burden and costs they entail. Moreover, they can easily be integrated into their urban (and social) environment.

Elevation

Ruukki Health Clinic

Architect

alt Arkkitehdit; Architecture Office Karsikas

Ruukki, Finland Client

Municipality of Siikajoki

Completion

2014

Floor area

910 m2

Located next to a senior citizens’ assisted living and care center, the Ruukki Health Clinic reaches out to the local community, adding a dental clinic and simple healthcare services, among them facilities for childcare. Ruukki is a small community of some 4,500 inhabitants in the province of Oulu, located in the Northern Ostrobothnia region of Finland, and the health clinic site is surrounded by pine forests. The building has two linear and one concave façade, resulting in a curved L-shaped plan. Most treatment areas and consultation rooms are located along the perimeter of the outer façade

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Ground floor plan

The elegantly curved, wooden façade with the main entrance | View from the parking lot to the main façade | Views of hall at the center of the building with social area

of this L-shaped building; wide ribbon windows offer views of the adjacent pine woods. The inner side of the building is marked by a curved wall that is interspersed with windows in a seemingly random order, lending the building’s entrance a humane and playful character. Wooden frames protrude outwards to the square in front, marking the entrances. The façades are clad in larch wood, that will gray over time, and anodized aluminum. Jutting forward, the wooden roof protects the glazed parts underneath from the impact of inclement weather conditions. Architect VillePekka Ikola from alt Arkkitehdit explains that ‘ample eaves protect the cladding from weather

and connect the embracing, free-form wall to the older buildings with its stern but polite profile.’ The main entrance in the middle opens to a spacious lobby that gives access to the two corridors that lead to the spaces for consultancy and treatment. The dental care, healthcare, and child healthcare facilities are distinct units grouped around the central lobby at the core of the building. The end of the corridors are left open, preventing the impression of dead-end streets. Finnish birch veneer and white façades give the interior a friendly, almost homely character. Though relatively small, the clinic has

a strong presence, its contemporary architectural language contrasting with the adjacent buildings. The project was a collaboration with Martti Karsikas (Architecture Office Karsikas) and was exhibited in the Nordic Pavilion at the Venice Biennale 2016.

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Sections San Blas

Municipal Healthcare Centers San Blas, Usera, Villaverde

Architect

Estudio Entresitio

Client

Madrid+Salud, Madrid City Council

Completion

2010

Madrid, Spain Floor area

1,989 m2 (San Blas, Villaverde); 1,452 m2 (Usera)

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Standardization has been a key issue in architecture since times immemorial, and hospitals prove that the repetition of tested solutions is not limited to mass-produced housing. In this building category, standardizing ranges from floor plans for patient rooms, for instance, to the layout of outpatient departments. The three municipal healthcare centers designed for Madrid are exceptional for repeating the same floor plan, practically without alterations. If the program is identical, why should the architectural solutions differ? Local conditions did not matter: all three are situated in non-descript environments dominated by social housing

Elevations Villaverde

Concrete façade of San Blas Healthcare Center | Interior with patio at San Blas | Circulation spaces at San Blas

(which is also often standardized). For all three sites, the architects opted for a sculptural solution of abstract volumes that, except for the entrance, are completely closed on the outside. At first sight, this gives the impression of a series of stacked containers: the height differs but the geometrical grid determines everything. According to the designers, these are placeless buildings – which implies that all places suit them equally well. The interior of the health centers is a composition of public and private rooms alternated by 13 patios and accessible from three corridors that

also link the patios, thus preventing the typical long and drab hospital corridors and creating visual links in all directions, but not with the world outside, which is manifest only in the sky above. Only relatively simple medical consultations and interventions take place in these centers, which appear to anticipate a redistribution of healthcare services. The San Blas Healthcare Center was the first to open its doors. It is clad in concrete with the imprint of the wooden encasements clearly visible. It helps to prevent the composition of grayish volumes from

appearing like a bunker – instead, it looks like an abstract work of art, the more so since the higher parts of the façades facing the patios in the interior are kept in a strong, dark color. Blue tiles and views on plants in the patios produce a surprisingly elegant effect, which clearly refers to the architectural idiom of classical modernism. The Usera clinic is clad in a golden aluminum mesh, and the Villaverde project – which resulted from winning another competition – repeats the main features of its predecessors but with a slight variation: it is clad in translucent, whitish and shining panels that give the building a transparent feel.

MUNICIPAL HEALTHCARE CENTERS SAN BLAS, USERA, VILLAVERDE

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Elevations Usera

Golden aluminum mesh façade at Usera | General view of Usera Healthcare Center | The Villaverde façade consisting of glass and polycarbonate panels | Circulation and patio spaces at Villaverde

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OUTPATIENT CLINICS AND HEALTH CENTERS

Voids and volumes

Ground floor plan

Outer shell

Concept scheme Villaverde

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MUNICIPAL HEALTHCARE CENTERS SAN BLAS, USERA, VILLAVERDE

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Section AA

UCLA Outpatient Surgery and Medical Office Building

Architect

Michael W. Folonis Architects

Client

The Nautilus Group

Completion

2012

Floor area

4,645 m2

Santa Monica, California, USA

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This outpatient clinic by Michael W. Folonis (principal) and Rudy Gonzalez (project architect) acts as a satellite for a large inpatient facility across the street. The feel of the Outpatient Surgery Center and Medical Office Building is saturated by a characteristically Californian approach, its distinguishing feature being the continuous connection between in- and outdoors and the way daylight floods the interior. Furbishing the interior with natural materials, the typically Californian combination of modern geometry and domestic warmth creates a pleasant, almost leisurely atmosphere. Sightlines connect indoor planting with the landscape

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The central glass lobby glows at night | The center's main volume is divided into two concrete pavilions | Views of lobby with staircase | Ground floor with waiting area

outside; exterior patio gardens on the ground floor invite patients to wait outside. Plants also enliven the waiting areas on the second floor, where lightwells provide daylight. Louvered windows avoid glare inside. Solar panels are mounted on the roof and provide up to 25 % of the building’s electricity. Other energy-saving features included the use of recycled steel. The program comprised an ambulatory-surgery clinic with eight operating theaters, a radiationoncology clinic, a blood lab and general clinics in a building of only three floors. Creating two box-like volumes that cantilever outward from a

set-back ground floor and filling the space in between with an expansive, three-storied lobby, Folonis achieved a simple overall layout. The lobby serves as a logistical hub. A full-height, mullion-free glass wall, in combination with a glass skylight, floods it with light. Internal spaces facing the lobby receive indirect daylight through pocketed windows. The larger of the box-like wings accommodates most of the hospital processes, the smaller is used for supportive functions. Bridges on the first and second floor connect both. California is dominated by lowrise, suburban sprawl and there is little alternative to the use of private vehicles, creating the

need for car parking. At UCLA’s ambulatory center a fully automated parking system has been installed. There are six drop-off points that provide the visitors with instructions via LED signs that give access to this system. Cranes carry the car to a platform that assigns it to one of the 380 parking places in six levels underneath the building, a solution that saves 50 % of the space needed for this many cars. The automated system will reduce the number of kilometers wasted by searching for an empty lot by more than 1,500; moreover, the time needed to retrieve the car is only two minutes.

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New QEII Hospital

Architect

Penoyre & Prasad

Welwyn Garden City, UK

Client

Assemble Community Partnership; NHS Hertfordshire

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OUTPATIENT CLINICS AND HEALTH CENTERS

Completion

2015

Floor area

8,500 m2

The new QEII Hospital in Welwyn, in Hertfordshire, one of England’s first garden cities, has very little in common with the traditional, bulky complexes Britain’s National Health Service produced for several decades. Its scale is comparatively modest; the design is friendly and refers to the vernacular of the original idyllic scenery of the site. With an outpatient department, ante/ post-natal care, some diagnostic facilities (e.g. X-rays, MRI and CT scanning), day wards and a hot floor with medical functions, the building anticipates the inevitable redistribution of healthcare facilities toward local and primary care. It does not provide surgery – although it

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does have an endoscopy department. In its urgent care center, only minor incidents are treated, and the ambulance facilities are planned for light duty. It has no inpatient beds. Patients who need advanced treatment will be routed to Lister Hospital in the neighboring town, or to other, more centralized, acute and tertiary medical institutions that in the future are expected to concentrate on high level cure. The New QEII Hospital is designed as a prototype of a new kind of facility and adopts a new role, namely that of a community-based health center that ideally bridges the gap between crisis management (the traditional hospital) and prevention

(providing information and support). Befitting a garden city, the building’s three interconnected L-shapes are organized around an almost square garden. All waiting areas are located next to this central courtyard garden; bathed in daylight, they offer a serene view. Above the timber-clad colonnaded entrance the top floor is cantilevered, offering visitors protection against inclement weather. The triple-height hall with a giant mural by David Tremlett suggests that the landscaped zone outside infiltrates the building and connects to the garden in the courtyard. While the two-story

wings respond to the domestic scale of the surroundings, the building partially rises to four levels under a sloping monopitch roof, clad in zinc-coated aluminum. This pitched roof creates a rhythmic composition. All main elevations are clad in hand-glazed ceramic tiles. Glass, render and in particular the timber-lined walls and soffits of the protected walkways contribute to a friendly impression. The opening windows are protected by laser-cut metal screens by artist Charlotte Mann, thus avoiding security bars. The building was designed to high energy-efficiency standards and achieved a BREEAM ‘excellent’ rating.

NEW QEII HOSPITAL

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Outpatient Clinic Hospital-Asilo of Granollers Granollers, Spain

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Architect

Pinearq

Client

Fundació Fransesc Ribas

Completion

2009

Floor area

19,500 m2

In Barcelona, art-nouveau architects like Lluís Domènech i Montaner and Antoni Gaudí defined Catalan Modernism. As part of this movement, Josep Maria Miró i Guibernau realized the Hospital General de Granollers in 1910, Granollers being located some 25 km north of Barcelona. Lacking the grandiosity of Domenech’s Sant Pau and the exuberance of much of Gaudí’s work, it is nevertheless a listed building. Its U-shaped volume embraces a court with trees in the central part, in front of the two towers that mark the central axis of the building. Originally, the main entrance was located precisely in the middle, between the towers. In the course of time

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Façade of the new wing looking toward the historical building | Connection between the extension and the historical building

buildings were added to the back and to the right, which absorbed most of the hospital functions. Slightly oblique, a large, two-storied house (referred to as ‘Historical Home’) was built at the back of the old hospital. The architects of Pinearq, Juan Manuel Garcia, Carlos Frauca, Gerardo Solera and Pedro Pombinho, decided to keep the larger, perpendicular hospital blocks and empty the terrain between the original hospital, which now serves mainly administrative functions, and the new house. On that site, the new day hospital forms a rectangular volume that runs parallel to the base of the U-shaped historical building, connected with it via an

entrance hall and a patio. Acting as a central area that gives access to all departments, the extension serves as the logistical hub of the entire hospital, bringing back the functional coherence that was lost by adding extra volumes seemingly at random. The entrance hall can be reached via a connection that pierces through the old building, to the left of the original entrance. With its four floors, the new addition is slightly higher than the original monument, which has two floors topped with the steep roofs of the attic. The lower floor of the two-level basement has an external access patio for the supply of medical

gases, some of the maintenance areas and a services pit that connects to the new services facilities building. At the level above, the vehicle access to the mortuary, the exit for dirty laundry, supply and storage spaces as well as the pathology department can be found; though not part of the outpatient facilities, the new building’s infrastructure was used to restructure the entire hospital. A tunnel connects this floor to the geriatric department. The new entrance at the ground floor provides access to the hall and the day hospitals in the extension. The first floor can be accessed either from the main hall or from the ground level entry placed at the backyard.

OUTPATIENT CLINIC HOSPITAL-ASILO OF GRANOLLERS

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1 Main access 2 New outpatient building 3 Historical building 4 Geriatric facilities 5 Existing buildings 6 Access to outpatient building

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This level contains part of the hot floor with the major ambulatory surgery unit and endoscopies room. The two parallel wings on the back of the extension house the medical support offices. The second floor has a leveled access from the backyard. Most of the medical offices and their support rooms are situated on the second and third floor. These two floors also provide level connections with the Historical Home that still awaits refurbishment. The fourth floor is for the facilities services. The new wing is conceived of as a screen that sets the stage for the listed building. The effect

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of a screen is enhanced by cladding the entire façade in wooden lamellae pierced at irregular intervals with vertical openings that mark the windows and allow fire fighters emergency access. The façade facing the other sides repeats the rhythm over vertical openings at the three lower floors, which are clad in dark slate tiles, while the top services floor is finished in natural color corrugated aluminum sheet and endowed with wider ventilation grids. Two parallel volumes stretch out in the landscaped surroundings, repeating the open courtyard of the historical building at a smaller scale. In the entrance hall, warm, dark wood combines with the broken white

of the floor and the gray of the columns to create a comforting atmosphere.

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Façade of the new wing | Evening view of the open space between the two wings at the back | Entrance | View toward one of the two wings at the back of the building

OUTPATIENT CLINIC HOSPITAL-ASILO OF GRANOLLERS

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Rehabilitation and Support Clinics

Having completed all steps of a medical therapy in a hospital, patients sometimes need additional physical and psychological rehabilitation and treatment before they can go back to leading their normal lives. Rehabilitation can be integrated into the hospital services or be provided in specialized clinics. Some people need to stay in the rehabilitation facility, others can be treated as outpatients. Rehabilitation is the last step of a care pathway. The quality, adequacy and timeliness of rehabilitation plays a crucial role in improving outcomes and keeping the length of stay in a hospital as short as possible. Typologically, rehabilitation clinics resemble hotel-like facilities – especially when the complexity of the required medical care and interventions is relatively low. It is recommended to keep therapy spaces, patient rooms, guest rooms and day treatment facilities separated. If patients spend several weeks at these centers, leisure options and spaces for cultural activities should be included.146 Support clinics are of a different nature; their focus is not on healing patients, but rather on supporting them in times of hardship. Unlike many standalone rehabilitation clinics, they are usually built in the vicinity of hospitals. Often, patients use them while being treated at hospitals nearby. Best known among the support clinics are the Maggie’s Centres in the United Kingdom, which help cancer patients cope with their disease. These centers are named after Maggie Keswick Jencks, who was diagnosed with breast cancer and subsequently, prior to her death in 1995, worked closely with her husband Charles Jencks and her medical team to develop a new approach to cancer care. Jencks invited several leading architects to design Maggie’s Centres which result-ed in an impressive series of small, fascinating buildings. Their example has inspired similar initiatives in other countries such as Norway.

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Courtyard | Lush landscaped garden

Maggie’s Centre West London

Architect

Rogers Stirk Harbour + Partners

Client

Maggie’s Centres

Completion

2008

Floor area

370 m2

London, UK

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The various Maggie’s Centres in Great Britain are drop-in facilities dedicated to providing support and an uplifting environment for patients with cancer. Typically located next to a hospital, they offer a caring environment. Founded by and named after Maggie Keswick Jencks, the wife of architectural theorist Charles Jencks, the first one opened in Edinburgh in 1996 and 15 centers have been built since. Maggie Jencks, who died of cancer in 1995, believed in the ability of buildings to uplift people and it is not surprising that Maggie’s Centres have been designed by leading architects. No formal registration process is required to use the center that typically includes

Section

Elevation

The kitchen is the heart of the center | Informal social area | Courtyard with trellis

a garden and a kitchen and makes the most of good-quality materials to create a soothing environment. Maggie’s West London, located on the grounds of Charing Cross Hospital, was opened in 2008. It sits on the front northwest corner of the hospital site, on a busy intersection of roads, bordered by a car park. The bright orange pavilion set within the newly-landscaped grounds was inspired by the concept of a heart enveloped by the protective wrap of a building’s four walls which act as counterpoint to the austerity of the hospital. The floating roof that oversails the outer wall

and helps flood the space with light, the protective walls and the windows opening into one of three courtyard gardens, all work to embrace the visitors and draw them into the kitchen, which is at the center of the building. The heart is created by a double-height communal space that serves as an atrium and a piazza, surrounded by a library and a series of large and small sitting and discussion rooms, which are more domestic in scale. Birch-finished plywood and polished concrete floors soak up the daylight that streams in through the glazing, and transitional walls provide the flexible space needed to accommodate both private chats and yoga classes. In creating an

intimate but open and welcoming space, Maggie’s West London embodies a new typology of hospital building, one which values the individual above the institution, with healthcare expressed through a holistic experience of nature, light, comfort and togetherness rather than medical processes alone.

MAGGIE’S CENTRE WEST LONDON

249

East elevation

Section AA

COUNSELING ROOM - MEDIUM

DINING ROOM

Views toward the courtyard | Kitchen | Small counseling room

Maggie’s Centre Gartnavel Glasgow, UK

250

REHABILITATION AND SUPPORT CLINICS

Architect

OMA

Client

Maggie’s Centres

Completion

2011

Floor area

534 m2

Maggie’s Gartnavel was the eighth Maggie’s Centre in the UK. It serves the west of Scotland’s population – an area with a high incidence of cancer. It is located close to Gartnavel General Hospital and also to Scotland’s leading oncology facility, the Beatson West of Scotland Cancer Centre. When OMA – Office for Metropolitan Architecture, based in Rotterdam and led by founding partner Rem Koolhaas – friend and former student of Charles Jencks – and the partner in charge of the project, Ellen van Loon, received the assignment to design a Maggie’s Centre, they decided against creating a piece of iconic architecture. The task at the Glasgow

Medium counseling room

Small counseling room

Medium counseling room

Large room

Library

COUNSELING ROOM - MEDIUM

COUNSELING ROOM - SMALL

A

LARGE ROOM COUNSELING ROOM - MEDIUM

COUNSELING ROOM - SMALL

LIBRARY

Office

OFFICE 2

Dining room

Small counseling room

OFFICE 1

KITCHEN

DINING ROOM

0

5m

Kitchen

A

Ground floor plan

center was to create a small, intimate environment for people who are confronted with an existential crisis. In the Maggie’s Centre in Glasgow, all rooms have been arranged around a central garden. Seemingly distributed at random, the borders between the spaces are fluent, inviting the center’s users to stroll through the building and enjoy the succession of different scenes. Situated on a hill, the rooms provide views to the campus of the Gartnavel General Hospital and to the city. The center is surrounded by a landscaped zone designed by Lily Jencks, daughter of founder

Axonometric diagram

Maggie Keswick Jencks. The interlocking rooms are arranged around a central garden and nature is an essential element of the center. The green spaces outside mark a transition zone that conveys a clear message: here you leave the hospital and enter an entirely different world, one dedicated to support and comfort. Upon entering the center, the succession of spaces – living rooms, larger spaces for social interaction, a library, a kitchen – follows a logic that seeks a balance between privacy and the publicness of the community of patients seeking relief. Key to the plan is an arrangement of L-shaped rooms that are able to accommodate the whole range

of emotions the patients experience at different moments during their stay. The room sequence has ramps that follow the topography of the sloping site and individual areas can be closed off by large sliding doors. A concrete roof with a beech ceiling lends coherence to the plan. The Maggie’s Centre in Glasgow is an architectural icon-in-reverse: it does not make any attempt to impress the outside world and instead focuses entirely on its interior atmosphere. Maggie’s Centre Gartnavel was the first UK building for OMA.

MAGGIE’S CENTRE GARTNAVEL

251

11

A’ Section AA

Section BB

Gheskio Cholera Treatment Center Port-au-Prince, Haiti

252

REHABILITATION AND SUPPORT CLINICS

Architect

MASS Design Group

Client

Les Centres GHESKIO

Completion

2015

Floor area

693 m2

Capacity

100 beds

Dedicated to the fight against HIV/AIDS, GHESKIO – the world’s first institution dedicated solely to this mission – was forced to address another problem in Haiti: the sudden outbreak of cholera. Paradoxically, the disease was brought to the island by the UN peacekeepers who were stationed there after the devastating earthquake of 2010. The lack of a hygienic infrastructure and the very poor and overcrowded housing conditions – characterized by the lack of a decent sewage system and an effective garbage disposal service – provided an ideal setting for the spread of the disease, which soon left its traces in the entire city.

Ground floor plan A 13

1 Reception 2 Shower room 3 Wash area 4 Severe ward 5 Main ward women

3 3

6 Main ward men

5

4

7 Main ward children 8 Observation

2

9 Administration 10 Chlorine prep room

B

B

11 Exit

6

12 Rainwater collection tank

1

13 Anaerobic baffled reactor

12 8 10

9

7 12

11

10m 8

6

4

2

0

10m 10m

N

A

Filtered rainwater reused in center

Rainwater collection cistern/planter

Wastewater recycled and treated to avoid recontamination of water table

to A.B.R. Water Table

B - B’

Strategies for water recycling, reuse, and treatment

Exterior view showing the roof that provides daylighting and natural ventilation | View of triage space and water cistern beneath an interior planter | Large shelving in the interior allows for quick access to supplies

The Cholera Treatment Center fights the disease at two levels simultaneously: it offers medical assistance for those who suffer from it – in most cases, cholera can be cured – while at the same time introducing preventing measures that address some of the environmental issues that caused cholera to become epidemic. In particular, it incorporates an on-site wastewater treatment facility to thwart recontamination of the water table and subsequent spread of the disease, treating up to 950 m3 of wastewater annually. The clinic’s cure facilities are accommodated in a building with a remarkably simple floor plan.

There are 35 places for mild cases and 65 for severe cases. Medical professionals take care of them. The clinic derives its most striking features from the decision to design it as a small landmark building dedicated to the purification of water, polluted water being a major reason for the dissemination of cholera. The entire building is set 1 m above the ground, with a water basin underneath. The sculptured roof is not only a beautiful asset of the clinic, it also channels water toward a central collector, after which it is cleansed; part of it is used for the clinic itself, but the adjacent neighborhood also benefits.

The handcrafted metal shade system that is used for part of the outside wall has been calculated to enhance privacy, provide daylight and ensure ventilation. It was made by local metal workers who cut no less than 36,000 apertures in the screens. Also locally produced were the compressed, stabilized earth blocks that are the main building material. Finally, MASS collaborated with local craftsmen to produce furniture for the facility tailored to the needs of cholera patients.

GHESKIO CHOLERA TREATMENT CENTER

253

Ground floor plan

Cancer Counseling Center

Architect

EFFEKT Arkitekter

Client

Kræftens Bekæmpelse, Realdania

Livsrum, Denmark

254

REHABILITATION AND SUPPORT CLINICS

Completion

2013

Floor area

800 m2

The principal aim of the Cancer Counseling Center in Livsrum is to offer its visitors comfort, social support and relevant insight in the nature of the type of cancer they have to face and the therapies used to combat it. The program envisaged a library, a kitchen, private meeting rooms, a lounge, a workshop, a physical fitness area and a place for medical counseling. Instead of integrating all these functions in one single volume, EFFEKT designed seven buildings, all in the same, residential idiom. Three longstretched volumes, like all the others covered with a gabled roof, demarcate two courtyards, each of which is closed with two similar but

Roof plan

Evening view | View of courtyard | Social area

much shorter buildings. The height of the roofs differs, resulting in slopes of various grades. White is the buildings’ dominant color inside as well as outside. All façades facing outward are clad in white fiber-cement boards in horizontal stripes, the only exception being the entrance part, which is clad in narrow, vertical wooden panels. These are also used for all gables facing the interior courtyards, giving them a warm atmosphere. The entire roof is clad in the same white boards as the exterior façade; hiding the gutters and the rain pipes behind the cladding, the architects took care that nothing disturbs their simple geometry. White is also the domi-

nant color in the buildings’ interior finishes, but the floors and window casings are made from solid bamboo.

are. Located next to a hospital, this Counseling Center compliments the more invasive therapies provided there and provides a frame of reference for them to the patient.

The materials selected for the furniture include solid natural materials such as non-lacquered hard wood, leather and wool, which result in a modern and stylish yet comfortable, domestic interior. Part of the walls are entirely clad with wooden bookshelves that form a perfect square grid, with some of them painted white. Where they are lining outside walls pierced with windows, they are part of the window frame, suggesting that the walls are much thicker than they actually

CANCER COUNSELING CENTER

255

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Courtyard elevations: west, north, east and south

1

2

3

4

5

5

6

7

8

5

6

7

8

5

6

7

8

5

6

7

8

Views of the living room | Gymnasium

256

REHABILITATION AND SUPPORT CLINICS

6

6

6

6

Elevations

CANCER COUNSELING CENTER

257

Groundfloor

Roof

Ground floor plan

Roof plan

Groundfloor

General view from the east | North and east façade | Courtyard | View from the inside toward the terrace

Healthcare Center for Cancer Patients Copenhagen, Denmark

258

REHABILITATION AND SUPPORT CLINICS

Architect

Nord Architects

Client

Copenhagen Municipality

Completion

2009

Floor area

1,800 m2

Few diseases have a more ominous aura than cancer. Treatment often requires arduous chemotherapies, aggressive radiological interventions and complex surgery. It has increasingly become the domain of multidisciplinary teams that involve oncologists working together with specialists from different fields. Only large oncological departments can offer these services; often these departments have become specialized hospitals in their own right. However, smaller cancer centers have evolved in recent years as well, providing a less stressful environment for patients. The Healthcare Center for Cancer Patients is a fine example of this trend. Unlike the well-known

East elevation

East Elevation 1:200

Maggie’s Centres, which are entirely dedicated to support and inform patients, this center provides its patients with a range of therapies focused on patients’ well-being, in support of the medical interventions administered in large-scale facilities. Situated in a semi-residential area close to the university hospital, the center is immediately recognizable, even though its footprint does not go significantly beyond the scale of the building blocks adjacent to it. Clad in aluminum, the contrast with the dark red brick that dominates the neighborhood could hardly have been more conspicuous.

The architects decided to break up the volume, creating a mishmash of seemingly small houses with steep roofs lining an interior patio that nevertheless are part of one volume. Suggesting a diamond-shaped parceling structure, the rooflines of the allegedly individual houses are set at an angle of about 45 degrees to the alignment of the block. If the outer façade corresponds with the building line, this results in rooflines diagonally breaking away from it; if not, a dented perimeter is the outcome, producing the prismatic effect that characterizes the building’s exterior.

Whereas the external envelope with its pointed roofs and sharp turns appears to fend off inimical influences from outside, suggesting that the Center protects its patients, its inner world offers them comfort and support. Within the rectangular block, three long-stretched zones define the building’s overall structure. Leaving the central part of the middle zone open, the architects created a patio that acts as the heart of the building. Here, the façades are clad in wood, and the pavement is a simple brick in a warm color. Dotted with wooden street furniture, the atmosphere is domestic. With only three floors, the Center is modest in scale. It offers its

HEALTHCARE CENTER FOR CANCER PATIENTS

259

Wooden exterior cladding | Space for recovery programs on the first floor | Lobby space | Ceiling and skylights from below | General view from the southwest at night

users spaces for social support and enlightenment on the ground floor and rooms for athletic therapies on the floor above. The spaces on the third floor derive their character from the steep, pyramidal roofs. The Healthcare Center evolved from what the architects have labeled ‘process design’, an approach that required multidisciplinary work at the office and included both the users and experts from cancer rehabilitation.

260

REHABILITATION AND SUPPORT CLINICS

Sections

HEALTHCARE CENTER FOR CANCER PATIENTS

261

Site plan

Rehabilitation Center Groot Klimmendaal

Architect Client

REHABILITATION AND SUPPORT CLINICS

Stichting Arnhems Revalidatiecentrum

Arnhem, the Netherlands

262

Koen van Velsen Architects

Groot Klimmendaal Completion

2010

Floor area

13,800 m2

Capacity

60 beds

Winner of many awards, this rehabilitation center represents the first phase of a project that will ultimately replace the seven cluttered, low-rise pavilions, forming a somewhat dispersed campus, by three larger buildings; the area now occupied by the existing pavilions will be returned to nature. Supported by a forest of beams, the top floor of Koen van Velsen’s 120Æm long clinic hovers high above the entrance, anticipating the planned extension. 3,400 rehabilitants will be treated here each year. The rehabilitation therapies offered here focus on children and on patients suffering from respiratory problems. All therapeutic facilities are grouped together in

Longitudinal section

Evening view of façade | The dented walls provide glazed alcoves | The building in its woodland surroundings | View of alcove space from the inside

this building; the additional building volumes will accommodate a school and staff housing. The ground floor is designed as an open space that contains several blocks with semi-public functions: a sports hall, a swimming pool, a theater and the restaurant. When not in use, these are open to the public. The glass walls offer a view onto the woods in which the building appears to hide itself. Painted dark brown, a series of V-shaped steel beams is left exposed, contrasting with the right angles of the floors, the balustrades, the subtle grid of the windows and the lightwells. Using bright colors – dark blue, light green, yellow, orange – as sometimes rather dominant accents

against a palette of light beige background tints, the architecture emphasizes the interplay of planes and lines intersecting at right angles. The colors produce a lively, light atmosphere without evoking an overly playful impression. Seemingly hovering above an abyss where the terrain slopes, what appear to be five glass-encased vitrines protrude into the woods, forming a dented wall that makes the border between building and nature fluid, an effect enhanced by the reflections in the glass. The special functions are located on the ground floor and the level above. Consultancy rooms are situated on the

second floor; the third is the domain of the inpatients. Here we find 60 bedrooms overlooking the landscape, four salons where patients and visitors can meet and a central area with four lightwells. The roof is reserved for a Ronald McDonald house where parents can stay the night. By saturating the building with visual connections between the floors (using patios, lightwells and staircases) and from the floors to the surroundings, and by using unusually wide corridors as part of the sequence of spaces on each floor, Koen van Velsen creates the suggestion of a palimpsest of overlaid trajectories that invite people to take part in this play.

REHABILITATION CENTER GROOT KLIMMENDAAL

263

Cross sections

View of the generous circulation spaces characterized by bright colors | Lecture hall | Swimming pool

264

REHABILITATION AND SUPPORT CLINICS

6

7

7

7

7

6

Third floor plan

8

5 8

First floor plan

4

3

2

Ground floor plan

1 Entrance 2 Gymnasium 3 Swimming pool 4 Theater 5 Fitness center 6 Patient room 7 Living room 8 Void

REHABILITATION CENTER GROOT KLIMMENDAAL

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Second floor plan

Anti-Aging Life Center Chaum Seoul, South Korea

Architect

KMD Architects

Client

CHA Health Systems

Completion

2011

Floor area

18,580 m2

One may wonder whether aging should be seen as a medical condition, though every once in a while medicine presents new therapies that allegedly work wonders for longevity. While eternal life may not be an option, methods to counteract the unpleasant effects of old age may be within reach – although most old age problems are the product of unhealthy lifestyles in the past. Exploring strategies for coping with age-related medical problems is one of the goals of Chaum. The Anti-Aging Center is located within an existing 65,000 m2 mixed-use building and part

266

REHABILITATION AND SUPPORT CLINICS

Third floor plan

The tower with the clinic | Reception | Organic forms of the corridor on the second floor | Cubicles defined by curtains

of a medical network. The building is on a medical campus, next to a residential tower. The project’s program consists of a combination of a diagnostics center, medical spa, fitness and health counseling, dietary and nutritional training and advanced tissue storage and gene therapy. While it houses highly advanced research specialists and imaging equipment, overall Chaum conveys the impression of a luxurious health club and also works that way: visitors can get an annual membership to use its services. The mission of the clinic is to help their customers to slow down aging by preventive measures. Situated on the second and third floors of an existing building,

Chaum’s clinicians begin a process of diagnostic examinations, starting with take-in conversations in translucent circular rooms. Visitors are then assigned a private honeycomb-inspired ‘hive cell’, where they stay in comfortable privacy throughout their diagnosis. The cells stand out from the wood-paneled walls with sleek, patterned panels marking their outside and they interlock with one another across the floor. The spaces in between continue the play of curved lines that is the design’s signal feature. The floors above accommodate the health club, featuring wooden floor and wood-paneled walls accented by a black ceiling with large, circular lamps, adding a five-

star hotel quality. The spa, with its indoor and outdoor pools, is the only part of Chaum not dominated by warm colors and materials: here the aesthetic is sleek, modern and cool. The floors of the center are connected by a central atrium that is encaged in a trellis-like wooden shrine. Every part looks immaculate and clean, yet warm and friendly, and the architecture has an organic feel.

ANTI-AGING LIFE CENTER CHAUM

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INDEX OF PLACES

THE AUTHORS Cor Wagenaar teaches architectural and urban history at Delft University of Technology and was appointed Thomassen à Thuessink Professor at the University of Groningen, a dedicated chair focusing on the relation between architecture, urbanism and health, a joint venture of Groningen University and Delft University of Technology; in 2016, he became full Professor in the History and Theory of Architecture and Urbanism in Groningen. There he founded the Expertise Center Architecture, Urbanism and Health (www.a-u-h.eu), in which the Faculties of Art and Spatial Sciences, and the Medical Faculty cooperate. He published widely on the health impacts of architecture and urbanism (for instance Healthcare Architecture in the Netherlands, 2010, with Noor Mens), and urban history (culminating in Town Planning in the Netherlands since 1800. Responses to Enlightenment Ideas and Geopolitical Realities, 2011, second edition 2015). Noor Mens studied architectural history and urban planning. She worked as a freelance architectural and urban historian with a focus on healthcare architecture before she joined Eindhoven University of Technology, where she specializes in cultural heritage assessment methods for post-war housing estates. Among her numerous publications is De Architectuur van het Ziekenhuis. Transformaties in de naoorlogse ziekenhuisbouw in Nederland (co-authored with Annet Tijhuis, 1999), the first comprehensive overview of hospital architecture in the Netherlands, followed by a similar publication on the architecture of psychiatry and the architecture of cure and care facilities for the elderly. She also wrote extensively on urban history, focusing on modern planning between the world wars and the post-war reconstruction. Guru Manja is a co-founder and partner at CEANconsulting, assisting hospitals, nursing homes and psychiatric institutions with the development and optimization of healthcare concepts and business models. Originally trained as an electrical engineer, he has built up extensive experience and in-depth knowledge of healthcare processes, safety regulations and financial and data analysis. He specializes in the optimization of healthcare operations, financial performance, capacity utilization, programming and building layout. He also assists healthcare providers with tendering, contracting and managing design and build projects. Colette Niemeijer is an architect and co-founder and partner at CEANconsulting, where she advises hospitals, nursing homes and psychiatric institutions on healthcare architecture and new healthcare concepts. As a program manager, she supervises healthcare building projects, from concept development through the design and build phases. She specializes in the integrated optimization of building design, healthcare processes and logistics, the development of master plans and project briefs, and transition and

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program management. She holds a PhD in architecture and wrote her dissertation on ‘The Added Value of Architecture for Healthcare in Hospitals’ (Delft University of Technology, 2012). Tom Guthknecht received his diploma in architecture from the Technical University Karlsruhe and a Master of Arts in Health Facility Planning from the University of North London. He did his PhD on hygiene planning at the Technical University Stuttgart and completed his post-doc research (habilitation) at the ETH Zürich, where he now teaches health facility planning. He has practical experience as an operating theater nurse and went back to nursing during his studies to fresh up his on-site expertise in care. He gathered professional experience in the field of health facility planning in various countries in Europe as well as in the Asia-Pacific region and is an architect licensed by the German Chamber of Architects as well as the Swiss Institute of Engineers and Architects (SIA). He was also in charge of a research and realization project in high-end optical spectroscopy. He currently heads the restructuring of the hospital in Biel, Switzerland, and acts as a consultant to various international healthcare projects. His research focus is on ‘Reduction of patient fear: a key to a successful healing environment’. Giuseppe Lacanna is a certified healthcare architect with a specialization in Public Health Measurements from the Harvard T. H. Chan School of Public Health. He was a researcher at Chalmers’ Center for Healthcare Architecture in Göteborg, Sweden. At the Faculty of Architecture and the Built Environment of Delft University of Technology, he specialized in evidence-based design research, Lean Six Sigma techniques and UX (user experience) design in order to create patient-oriented and financially viable healthcare environments. Since 2016, Giuseppe Lacanna has been part of the Young Leaders Group of the UIA Public Health Group. Peter Luscuere is Professor of Building Services at Delft University of Technology and visiting Professor to Tianjin University in China. His research interests are climate design, sustainability, circular economy and exergy. As director at the engineering consultancy Royal Haskoning he was responsible for the company’s work in healthcare as well as developing a companywide Cradle-to-Cradle program on sustainability. In 2010, he established the independent consultancy Inspired Ambitions, while continuing his academic work. He developed a holistic approach ‘Beyond Sustainability’ in which renewability for all basic natural resources such as energy, water, air and soil is investigated. In 2016, he chaired the Transition Pathway Circular Economy within the Roadmap Next Economy, a project with Jeremy Rifkin for the metropolitan region Rotterdam The Hague.

Abu Dhabi, United Arab Emirates Cleveland Clinic Abu Dhabi 156, 157 Amersfoort, the Netherlands Meander Medisch Centrum 59, 63, 152–155 Amsterdam, the Netherlands 13 Academic Medical Centrum (AMC) 51, 64, 70, 85, 86 Emma Kinderziekenhuis 66 Arnhem, the Netherlands Rehabilitation Center Groot Klimmendaal 262–265 Angers, France Hôtel-Dieu 42 Bangalore, India Victoria and Vani Vilas General Hospital 65 Barcelona, Spain Outpatient Clinic Hospital-Asilo of Granollers 244–247 Sant Pau 244 Basel, Switzerland Bürgerspital 48, 49, 50 Bath, UK CircleBath 63, 85, 118–121 Beaune, France Hôtel-Dieu 42 Belfast, UK Antrim Maternity Hospital 33 Bergen op Zoom, the Netherlands Ziekenhuis Lievensberg 88 Berlin, Germany Charité 43, 44 Krankenhaus Neukölln 51 Städtisches Krankenhaus am Friedrichshain 45, 47 Unfallkrankenhaus 14 Bern, Switzerland Inselspital 43 Bradford, UK Bradford Royal Infirmary 103 Butaro, Rwanda Butaro District Hospital 122, 123 Chicago, Illinois, USA Ann & Robert H. Lurie Children’s Hospital 176–181 Copenhagen, Denmark 100 Healthcare Center for Cancer Patients 63, 258–261 Deventer, the Netherlands Deventer Ziekenhuis 59, 76, 84

Düsseldorf, Germany Center for Surgical Medicine, University Hospital Düsseldorf 188–191

Lille, France 47, 48 Private Hospital Villeneuve d’Ascq 124–127

Edinburgh, UK 248

Linz, Austria Diakonissen Linz 83

Enschede, the Netherlands Medisch Spectrum Twente 142–147

Livsrum, Denmark Cancer Counseling Center 254–257

Florence, Italy Foundling Hospital (Ospedale degli Innocenti) 42

London, UK 18 Cancer Centre at Guy’s 228, 229 Charing Cross Hospital 249 Maggie’s Centre West London 248, 249 Royal Hospital Chelsea 43 Royal Naval Hospital, Greenwich 43 St. Thomas Hospital 45, 46

Frankfurt am Main, Germany Johann Wolfgang Goethe University Hospital 200–203 Glasgow, UK Beatson West of Scotland Cancer Centre 250 Gartnavel General Hospital 250 Glasgow Royal Infirmary 101 Maggie’s Centre Gartnavel 250, 251 Granollers, Spain Outpatient Clinic Hospital-Asilo de Granollers 242–245 Groningen, the Netherlands Diakonessenhuis 50 Martini Ziekenhuis 75 University Medical Center Groningen (UMCG) 53, 59, 60, 62 Haaksbergen, the Netherlands 142 Hamburg, Germany 16, 18 Städtisches Krankenhaus HamburgEppendorf 45–47 University Hospital Hamburg-Eppendorf 86 Heidelberg, Germany National Center for Tumor Diseases 41, 220–223 Hillerød, Denmark New North Zealand Hospital 10 Hoofddorp, the Netherlands Spaarne Ziekenhuis 70 Hoorn, the Netherlands Westfriesgasthuis 135 Hvidovre, Denmark Hvidovre Hospital 50, 141 Innsbruck, Austria Kinder- und Herzzentrum 58 Kolding, Denmark Kolding Hospital 58, 128, 129 Kortrijk, Belgium AZ Groeninge 130–133 Las Vegas, Nevada, USA 156 Cleveland Clinic Lou Ruvo Center for Brain Health 64, 210, 211

Los Angeles, California, USA 65, 75 Martin Luther King, Jr. Outpatient Center 69 Losser, the Netherlands 142 Lyon, France Surgical Clinic of La Croix-Rousse 212–215

Hôpital Lariboisière 45, 46 Hôpital Necker-Enfants Malades 224 Institut Imagine 224–227 Port-au-Prince, Haiti Gheskio Cholera Treatment Center 252, 253 Portland, Oregon, USA Randall Children’s Hospital at Legacy Emanuel 164–167 Purmerend, the Netherlands Waterlandziekenhuis 135 Rennaz, Switzerland Hôpital Riviera-Chablais 140, 141 Rotterdam, the Netherlands Daniel den Hoed Cancer Institute 205 Dijkzigt Ziekenhuis 205 Education Center Erasmus MC 204–209 Erasmus MC Hospital 204–209 Ronald McDonald house 205 Sophia Children’s Hospital 205

Madrid, Spain Municipal Healthcare Center San Blas 234–237 Municipal Healthcare Center Usera 234–237 Municipal Healthcare Center Villaverde 234–237 Rey Juan Carlos Hospital 64, 148–151

Ruukki, Finland Ruukki Health Clinic 232, 233

Melbourne, Australia Royal Children’s Hospital 182–185

San Francisco, California, USA Maimonides Hospital 48, 49

Milan, Italy Ospedale Maggiore 42

Santa Monica, California, USA UCLA Outpatient Surgery and Medical Office Building 58, 238, 239

Montreal, Canada Centre hospitalier de l’Université de Montréal (CHUM) 77 Murcia, Spain Los Arcos del Mar Menor University Hospital 60, 90 New York, New York, USA Brooklyn Navy Yard Hospital 47 Columbia University Medical Center (Presbyterian Hospital) 47, 48 Cornell Medical Center 47, 48 Fort Hamilton Veterans Hospital, Brooklyn 50 Milstein Family Heart Center, NewYorkPresbyterian Hospital 216–219 Milstein Hospital 216 Oldenzaal, the Netherlands 142 Orlando, Florida, USA Nemours Children’s Hospital 160–163 Oslo, Norway Akershus University Hospital 37, 39, 196–199 Padua, Italy 44 Paris, France 44 Hôpital Beaujon, Clichy 47, 49 Hôtel-Dieu 42, 44, 45, 46

Saint-Lô, France Franco-American Memorial Hospital 50

Schiedam, the Netherlands Vlietland Ziekenhuis 63 Seoul, South Korea Chaum Anti-Aging Life Center 266–267 Seville, Spain Hospital de la Caridad 16 Siena, Italy 15 Sittard, the Netherlands Maasland Ziekenhuis (Orbis Hospital) 53, 69 Stockholm, Sweden Södersjukhuset 48, 49, 50 Stonehouse, UK Royal Naval Hospital 43 Stuttgart, Germany Robert Koch Krankenhaus 76 Swindon, UK Princess Margaret Hospital 50, 51 Terneuzen, the Netherlands Julianaziekenhuis 50

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The Hague, the Netherlands Haga Ziekenhuis 32, 40, 168 Juliana Children’s Hospital (Juliana Kinderziekenhuis), 40, 168–171 Ziekenhuis Leyenburg 168 Tonnerre, France Hôtel-Dieu 42 Trondheim, Norway St. Olav’s Hospital 62, 63, 192–195 Vienna, Austria Allgemeines Krankenhaus 43, 44 Gottfried von Preyer’sches Kinderspital 173 Mother-Child and Surgical Center, Kaiser-Franz-Josef-Spital 172–175 Welwyn Garden City, UK New QEII Hospital 240, 241 Woolwich, UK Royal Herbert Military Hospital 45, 46 Wroclaw, Poland Akademicki Szpital Kliniczny 66 Zaandam, the Netherlands Zaans Medisch Centrum 58, 134–139

INDEX OF NAMES Aarhus Arkitekterne 64 Abels, Harry 143 alt Arkkitehdit 232, 233 Anderson Mikos Architects 176–181 Andrésson, Birgir 198 Architecten aan de Maas 169 Architectengroep Duintjer 51, 64 Architecture Office Karsikas 232, 233 Atelier Christian de Portzamparc 212–215 Atelier Hiroshi Maeda 227 Atelier PRO architekten 59, 63, 152–155 Ateliers Jean Nouvel 224–227 Averulino, Antonio see Filarete Bartolo, Domenico di 15 Bates Smart 182–185 Baumschlager Eberle Architekten 130–133 Baur, Hermann 48, 49 Bazalgette, Joseph 18 Beer, Franz 43 Behnisch Architekten 41, 220–223 Billard Leece Partnership 182–185 Billard, Ron 182 Birch-Lindgren, Gustaf 47, 49 Bolink, Merijn 144 Bonnema Architecten 69 Bridger Carr Architects 103 Bouvier, Denis 140, 141 Brunelleschi, Filippo 42 Buchanan, Colin 54 Bulloch, Angela 229 Burger Grunstra Architecten 75 Bunshaft, Gordon 50 Buro North 184

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CannonDesign 77 Casa Solo Arquitectos 60, 90 Cassan, Urbain 49 Cederström, Hjalmar 47, 49 C. F. Møller Architects 37, 196–199 Codinhoto, Ricardo 40, 41 Coolidge, Shepley, Bulfinch and Abbott 47 Coquéau, Claude-Philibert 45 Cragg, Tony 198 Creo Architekter 58, 128, 129 Currey, Henry 45, 46 D’Agostino, Fernanda 165 Dahl, Ophelia 122 Da Silva Architects 216–219 De Jong Gortemaker Algra 59, 76, 84, 88 De Portzamparc, Christian 212 De Vos, Fiona 38 DELTA 83 Descartes, René 12 Domènech i Montaner, Lluís 242 Eberle, Dietmar 130 EFFEKT Arkitekter 254–257 EGM architects 63, 204–209 Estudio Entresitio 234–237 Farmer, Paul 122 Filarete 42, 43 Folonis, Michael W. 58, 238 Foster + Partners 63, 85, 118–121 Frauca, Carlos 243 Galton, Douglas 45, 46 Garcia, Juan Manuel 243 Gaudí, Antoni 242 Gauthier, Martin-Pierre 45, 46 GD architectes 140, 141 Gehry, Frank 64, 210, 211 Geninasca, Laurent 140, 141 Gerl, Josef 43, 44 Gilbert, Emile Jacques 45, 46 Gonzalez, Rudy 238 Gropius, Martin 45, 47 Groupe-6 140, 141 Gschwendtner, Gitta 229 Guthknecht, Tom 131 Haagort, Arie 204 Hamilton, Kirk 37, 40, 101 Harbour, Ivan 229 Haussmann, Georges-Eugène 45 Healy, Judith 13, 24 Heinle Wischer und Partner 188–191 Herzog & de Meuron 10 HDR 156, 157 HKS 37 HMC Architects 69 Hounsfield, Godfrey N. 83 IAA Architecten 142–147 Ikola, Ville-Pekka 233 Itten + Brechbühl 25 James Gamble Rogers 47 Jean-Philippe Pargade Architectes 124–127 Jencks, Charles 38, 247, 248, 250 Jencks, Lily 251

Jenner, Edward 22 KAAN architecten 204–209 Karl Schmücker und Partner 14 Karres + Brands 169 Karsikas, Martti 233 Katzir, Ram 144 Keswick Jencks, Maggie 247, 248, 251 Kleihues, Josef Paul 51 Kloos, Jan Piet 50 KMD Architects 266, 267 Knox, Alexander 184, 185 Koen van Velsen Architects 262–265 Koolhaas, Rem 250 Kowalczyk, Jarek 66 Kruisheer & Hallink 62 Labryga, Franz 10 Leroy, Jean-Baptiste 45, 46 Llewelyn-Davies Weeks 50, 51 Lister, Jospeh 47 Long, Crawford W. 47 Lauterbur, Paul C. 83 Lynch, Kevin 65, 66 Mann, Charlotte 241 Mansart, Jules Hardouin 45 Martens, Karel 229 MASS Design Group 122, 123, 252, 253 McKee, Martin 13, 24 Mecanoo 58, 134–139 Mendelsohn, Erich 49 Meuser, Philip 11 Michael W. Folonis Architects 58, 238, 239 Mies van der Rohe, Ludwig 58 Miró i Guibernau, Josep Maria 242 Mul, Geert 144 MVSA Architects 32, 40, 168–171 Nelson, Paul 47, 50, 124 Neudecker, Mariele 229 Neuf architect(e)s 77 Nickl, Hans 174 Nickl & Partner Architekten 58, 172–175, 200–203 Nield, Lawrence 14 Nightingale, Florence 54 Nord Architects 63, 258–261 Nordic – Office of Architecture 192–195 Nouvel, Jean 224 Nutt, Ronald 83 OD205 66, 205 OMA 250, 251 Pasteur, Louis 47 Patijn, Wytze 59, 60, 62 Pei Cobb Freed & Partners 216–219 Penoyre & Prasad 240–241 Perkins + Will 76, 160–163 Petit, Antoine 45 Pierzo Conseil, Dominique 126 Pinearq 242–245 Plousey, Louis 49 Plummer, Henry 24, 26 Pombinho, Pedro 243 Posnett, John 24 Powell and Moya 50, 51

Poyet, Bernard 45 Prasad, Sunand 14 Prouvé, Jean 205 Quarin, Joseph von 43 Rafael de La-Hoz 64, 148–151 Ratio Arkitekter 192–195 Reiach and Hall Architects 101 Rogers Stirk Harbour + Partners 228, 229, 248, 249 Röntgen, Wilhelm Conrad 15, 83 Roosen, Maria 144 Root, Mable 24 Rothenburg, J. N. C. 18 Rovehead, Alexander 43 RPP Architects 33 Ruppel, Friedrich 47 Ruvo, Larry 210 Schmidt Hammer Lassen Architects 58, 64, 128, 129 Schmieden, Heino 45, 47 Semmelweis, Ignaz 47 Sherman, Harry 86 Sijmons, Karel Lodewijk 168 Silver, Daniel 229 Solera, Gerardo 243 Solomon Cordwell Buenz (SCB) 176–181 Stanley Beaman & Sears 160–163 Stantec 228 Stein, Morris A. 37 Studio Fuerte 66 Thieriot, Angelica 75 Tinker Imagineers 169, 171 Townsend, David 83 Tremlett, David 241 Ulrich, Roger 37, 40, 62, 161 Valdés Leal, Juan de 16 Valero, Bernard 224 Valero Gadan Architectes 224–227 Van Beek, Hans 152–155 Van Bentem, Hans 144 Van Dam, Karin 144 Van Loon, Ellen 250 Van Mourik, Dick 51, 64 Van Velsen, Koen 262, 263 Valtos Architecten 70, 85 Venhoeven CS Architecten 25 Viel, Charles-François 45, 46 Viergever, Aad 204 Virchow, Rudolf 16 Walter, Jean 47, 49, 124 Weenix, Jan Baptist 12 Wiegerinck Architecten 70 Wischer, Robert 52 Worthington, John 25 Wren, Christopher 43 Zimmer Gunsul Frasca Architects (ZGF) 164–167, 176–181 Zimmerman, Carl Johann Christian 47 Zimring, Craig 65

ILLUSTRATION CREDITS Cover Torben Ekserod Frontispiece Erick Saillet 10 Herzog & De Meuron/Vilhelm Lauritzen 12 Wikimedia Commons 13 Rijksdienst Cultureel Erfgoed (RCE) 14 Noor Mens 15 Wikimedia Commons 16 Wikimedia Commons 17 left from: David Walsh, Lewis Jones, The Röntgen Rays in Medical Work, London, 1902 17 right Archiv Deutsches Röntgen-Museum 18 top Princeton University Library, Historic Maps Collection 18 bottom www.architural-review.com 25 Itten + Brechbühl AG 30–31 CEANConsulting 32 MVSA 33 RPP architects 34–36 CEANconsulting 37 Guri Dahl 39 Torben Eskerod 40 MVSA 41 Adam Mørk 42 top F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heilund sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 42 bottom A. Husson, Etude sur les hopitaux considérés sous le rapport de leur construction de la distribution de leurs batiments de l’ameublement, de l’hygiène & du service des salles de malades, Paris, 1862 43 top left London Metropolitan Archives, City of London 43 bottom left London Metropolitan Archives, City of London 43 center F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heilund sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart 1903 43 right A. M. Murken, Vom Armenhospital zum Großklinikum. Die Geschichte des Krankenhauses vom 18. Jahrhundert bis zur Gegenwart, Köln, 1988 44 top left Luisenstädtischer Bildungsverein, Berlin 44 top right Institut für Geschichte der Medizin und des Krankenhauswesens, Aachen 44 bottom A. Husson, Etude sur les hopitaux considérés sous le rapport de leur construction de la distribution de leurs batiments de l’ameublement, de l’hygiène & du service des salles de malades, Paris, 1862 45 Bibliothèque Nationale de France, Paris 46 top left Bibliothèque Nationale de France, Paris 46 top center F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heil- und sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 46 top right F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für

Heil- und sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 46 bottom left F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heil- und sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 46 bottom right F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heil- und sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 47 top F. O. Kuhn, Handbuch der Architektur. Vierter Teil: Entwerfen, Anlage und Einrichtung der Gebäude. 5. Halb-Band: Gebäude für Heilund sonstige Wohlfahrtsanstalten. 1. Heft: Krankenhäuser, Stuttgart, 1903 47 center Shorpy Historic Photo Archive & Fine-Art Prints 47 bottom Staats- und Universitätsbibliothek Hamburg 48 top left The New York Library, New York 48 top right The New York Library, New York 48 bottom P. Nelson, Cité Hospitalière de Lille, Paris, 1933 49 top L’Architecture d’Aujourd’hui, 1938 49 bottom left Das Bürgerspital Basel 1240–1946, Basel, 1946 49 center right Wikimedia Commons 49 bottom right Bruno Zevi, Erich Mendelsohn: The Complete Works, Basel: Birkhäuser, 1999 50 top left Het Nieuwe Instituut, Rotterdam 50 top right Het Nieuwe Instituut, Rotterdam 50 bottom Paul Vogler, Gustav Hassenpflug, Handbuch für den neuen Krankenhausbau, München, Berlin: Urban & Schwarzenberg, 1951 51 top Cover of brochure Princess Margaret Hospital Swindon 51 bottom AMC/Jan en Fridtjof Versnel 55–56 CEANconsulting 58 top left Stefan Müller-Naumann 58 top right Tom Bonner 58 bottom left Schmidt Hammer Lassen 58 bottom right Mecanoo 59 top left De Jong Gortemaker Algra/ Philip Driessen 59 top right KuiperCompagnons 59 bottom Dirk Verwoerd 60 Casa Solo Arquitectos 61 KuiperCompagnons 62 top KuiperCompagnons 62 bottom Grethe Britt Fredriksen 63 top left Narud Stokke Wiig Architects 63 top right CircleBath 63 center Adam Mørk 63 bottom left Dirk Verwoerd 63 bottom right EGM architecten 64 left Iwan Baan 64 top right Alfonso Quiroga 64 center right Schmidt Hammer Lassen 64 bottom Noor Mens 65 top Kevin Lynch, The Image of the City, Cambridge, 1960 65 bottom Victoria and Vani Vilas General Hospital, Bangalore 66 top left and right Studio Fuerte 66 bottom AMC/OD205/Mike Bink Fotografie 69 left HMC Architects/David Fennema

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69 right Bonnema Architecten 70 top AMC/Valtos Architecten/Luuk Kramer 70 bottom Wiegerinck Architecten 71–74 CEANconsulting 75 Burger Grunstra Architecten/Jan Buwalda 76 left Perkins + Will 76 right De Jong Gortemaker Algra/Philip Driessen 77 Neuf Architect(e)s and CannonDesign 80–82 CEANconsulting 83 DELTA 84 De Jong Gortemaker Algra/Philip Driessen 85 top AMC/Valtos Architecten/Luuk Kramer 85 bottom Foster + Partners/Nigel Young 86 AMC/Valtos Architecten/Luuk Kramer 88 De Jong Gortemaker Algra/Martijn Heil 90 Casa Solo Arquitectos 91–99 CEANconsulting 101 Reiach and Hall Architects 103 Telegraph & Argus 105–110 CEANconsulting 109 Drawing by CEANconsulting based on Royal College of Physicians, Acute Medical Care. The Right Person, in the Right Setting – First Time. Report of the Acute Medicine Task Force, London: RCP, 2007, p. 19, figure 2. 118–121 Foster + Partners/Nigel Young 122–123 Iwan Baan 124–127 Luc Boegly 128–129 Schmidt Hammer Lassen Architects 130 left Werner Huthmacher 130 right archphoto, inc. © Baumschlager Eberle Architekten 131 Werner Huthmacher 132 left Werner Huthmacher 132 right archphoto, inc. © Baumschlager Eberle Architekten 134–139 Mecanoo 140–141 Groupe-6; GD architectes 142 left Harry Cock 142 right Jannes Linders 143 Harry Cock 144 left Jannes Linders 144 right and bottom Harry Cock 148–150 Alfonso Quiroga 152–154 Dirk Verwoerd 156–157 Photos courtesy of HDR; © 2015 Dave Burk 160–163 Jonathan Hillyer 164–165 Nick Merrick, Hedrich Blessing Photographers 166 top left and top right, bottom left Eckert and Eckert Photography 166 bottom right Nick Merrick, Hedrich Blessing Photographers 168–171 Michel Kievits 172–174 Werner Huthmacher 176–177 Nick Merrick, Hedrich Blessing Photographers 178 top left, top center, top right Nick Merrick, Hedrich Blessing Photographers 178 center Eckert and Eckert Photography 178 bottom left and bottom right Nick Merrick, Hedrich Blessing Photographers 182 left Shannon McGrath 182 right John Gollings 183 John Gollings 184 left Shannon McGrath

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184 right John Gollings 185 top left John Gollings 185 top right, center right, bottom left, bottom right Shannon McGrath 188–189 Tomas Riehle 192–195 Nordic – Office of Architecture 196 Torben Eskerod 197 Torben Eskerod 198 top left, top center, center Torben Eskerod 198 center right Guri Dahl 198 bottom Torben Eskerod 200–202 Werner Huthmacher 204 left EGM architects 204 right Erasmus MC 205 EGM architects 206 top left Ossip van Duivenbode 206 top right, bottom left and right EGM architects 207 Fernando Guerra (FG+SG) 210 Matt Carbone Photography 211 left Iwan Baan 211 top center Dahl Photography 211 top right, bottom center, bottom right Matt Carbone Photography 212–214 Erick Saillet 216–218 Paul Warchol 220 left Adam Mørk 220 right Frank Ockert 221 left Frank Ockert 221 right Adam Mørk 222 Adam Mørk 224 Christophe Valtin 225–226 Patrick H. Muller 228–229 Morley von Sternberg 232–233 Courtesy of alt Arkkitehdit/ Ville–Pekka Ikola 234–236 Roland Halbe 238–239 Tom Bonner 240–241 Penoyre & Prasad/Tim Crocker 242–245 Fernando Guerra, Sergio Guerra (FG+SG) 248 Richard Bryant/Arcaid.co.uk 249 left Morley von Sternberg 249 center Richard Bryant/Arcaid.co.uk 249 right Morley von Sternberg 250 left Charlie Koolhaas 250 right Philippe Ruault 251 Philippe Ruault 252 Iwan Baan 253 MASS Design Group/Thatcher Bean 254 Quintin Lake 255 left Quintin Lake 255 right Thomas Ibsen 256 Thomas Ibsen 258–260 Adam Mørk 262 René de Wit 263 top left Rob 't Hart 263 bottom left Rob 't Hart 263 right René de Wit 264 René de Wit 266–267 KMD Architects Unless noted otherwise, all architectural drawings were kindly provided by the architects.