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