Description

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.[1] 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.

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.[2] 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. “Typical hospital configurations”) 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:[3]

Typical hospital configurations

A The theme model divides an often large-scale 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).

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 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 out-patient 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?[4] 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 manuever 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.

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 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.

Overview of functional zones within the hospital and possible design approaches

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.

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.[5] 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.

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.