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