ARCHITECTURE AND DESIGN-Guidelines and Health Care Building PDF

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“Guidelines and Health Care Buildings”   Fani Vavili, Dr.Architect, Professor Abstract What are guidelines, why we need them, by whom they are introduced? These are some of the questions that are intended to be approached in this presentation. Apart from the services they offered to the design proce...

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ARCHITECTURE AND DESIGNGuidelines and Health Care Building Fani Vavili World Hospitals and Health Services

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“Guidelines and Health Care Buildings”  Fani Vavili, Dr.Architect, Professor

Abstract What are guidelines, why we need them, by whom they are introduced? These are some of the questions that are intended to be approached in this presentation. Apart from the services they offered to the design process and the built environment especially in the health care facilities the main discussion today is if guidelines, norms, standards are necessary tools in healthcare design or they act as barrier in the creation of a proper healing environment

I. What are guidelines? A guideline is a general term. Several types of Guidelines rule the hospital: • Regulations (and government regulations): conforming to rule or imposed standard; prescribed by rule or law, prescribed rule or order • Specifications: detailed statement of work to be done, detailed list of orders • Norms: recognized standards • Standards: desirable level of efficiency • Instructions: orders or directions

II. The main objectives of guidelines are to harmonize and integrate in planning and design process a number of factors. Specifically the nature of the hospital, its momentous (complex) role, its users, the basic necessity for reliability (security, safety, responsibility, etc.) and also the need to control cost determine guidelines that are Ø aiming • at the creation of an acceptable hospital (Health Care) building • at the achievement of a safe, orderly and expeditious hospital (Health Care) building and • that the result signifies an economic hospital building National Guidelines also introduce norms, regulations etc in order to • clarify health care needs • define priorities within economic limitations and strict budgets and ensure that the final product (health services and the building) represents the best value for money

Rikshospitalet Oslo, 2001 Medplan AS Arkitekter

III. By whom, for what reason. Guidelines have a long story since the Greek Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

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temples, the Roman constructions and Vitruvius etc. But this presentation will be focused on guidelines for health care facilities. Ministries of Health introduce the basic and most relevant guidelines. Legislation and Circulars that are applicable to hospitals are introduced also by several Ministries such as • the Department of Housing: Building regulations, • the Dep. of Environment: Environmental regulations, Fire regulations/codes • the Dep. of Transport, etc. Several Ministries introduce standards and guides but also by other • governmental bodies e.g. SPRi in Sweden, Stakes in Finland, British Standards Institution, German Standard Institution (DIN), etc. • professional organizations e.g. National Association of Architects in Sweden, AAHA (American Academy of Hospital Architecture) etc. • Local Authorities and County Councils, published also directories • Disability alliances circulated design guides, rights handbooks, etc Plenty of publications (books, special magazines, guides) by researchers, architects, architectural practices. These guidelines, codes, specifications, measures, design guides, etc. give necessary information starting from A and arriving to omega at the alphabet of the steps needed in order to create a hospital. The available information is so abundant that you can find even details for a garden layout suitable for wheelchair users (Lockhart, T,). For example a Checklist for the bathroom design in order to ensure convenient living for an elderly and physically handicapped includes 17 recommendations: descriptions of materials, flooring details, width of the door, etc. (Brancon, G., pp.47) Several Department of Health and Social Security around the world have studied and introduced Health/Hospital planning Notes, Health/Hospital Building Notes, Health/Equipment Notes, Health Technical Memorandum, activity Data Base etc.

Rikshospitalet Oslo, 2001 Medplan AS Arkitekter

V. A. Hospital, Baltimore Cochran, Stephenson, Donkerviet, Inc.

Krankenhaus, Erfurt Germany Rossmann + Harder

IV. Guidelines content. The last fifty years there was, in most countries, a huge increase of guidelines for hospitals than for any other building type. The hospital design and construction became subject of the most demanding regulations and codes (planning, design, construction). The various guidelines cover • regional planning (hospital network) • functional aspects (location and access, space data etc.)

Rikshospitalet Oslo, 2001 Medplan AS Arkitekter

Nursing Home Leibnitz, Austria Klaus Kada

Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

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psychological factors – stimulation of the senses (colours, noise, odour, human scale, predictability, safety (security, fire protection, floods, earthquakes…), • privacy and independence (maintaining medical supervision), etc. • comfortability: temperature, seating etc., visual access to the outside environment, etc. Gallup, pp.115) • materials • morphological and esthetical aspects (match with the surroundings, human environment, symbol or identity, etc.) All these data are compromising and requirements are minimum. They certify compliance of the design proposals and accordingly the facility, to an essential, acceptable minimum. They certify also those main functions and their relationships; circulation principles, etc. are applied. •

Standards, norms, etc. are products of their time and they are the answers to pressing problems. Since the technology changes quickly they have to be subjects to continuous reform so the planner and designer to be aware of their validity.

V. The stereotypes. The urgent need, especially in Europe after the second world war, to develop health facilities had based on a great deal of research resulted huge amount of information. Hospitals, until recently, have been studied in depth in order • to avoid mistakes, • to reduce time from the moment of the decision to create a hospital until the opening day, • to control cost and • to involve more architects in the design process All these factors drove hospital researchers and governmental bodies (technical services at Ministries of Health) to introduce also prototypes (Prototype: earliest form of a layout, of a hospital, a model, a pattern). For example the British Harness Hospital Development program, the Nucleus templates, the Green Pack and the Nucleus Hospital overruled, not only in U.K.) hospital planning and design and for a long time prevailed over hospital architecture. The architectural drawing board when designing hospitals had, and still has, a prototype for a room, a group of rooms, a department, and even a whole hospital. I will give here an example of a similar strategy applied in Greece, a country of almost 10.000.000 people, from where I come. During the 80’s the development of primary care facilities became an urgent governmental policy in the frame of the country’s National Health System. The construction of 200 Rural Health Centers in a period of 4 years, was planned on basic decisions which were: a) to involve as many architects and engineers in the design process, b) to control the quality of design and c) to reduce construction cost. In order to achieve that the technical services of the Ministry of Health introduced detailed guidelines, they gave also prototype layouts (in the way of functional diagrams). Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

Greenwich General Hospital London, Tatoon Brown - DHSS

Wexham Park Hospital UK, Powell & Moya

Best Buy Hospital Frimley Park UK HDP & DHSS

Huddinge Hospital Stockholm

Chelsea Westminster Hospital, London 3

Two problems flourished through that: the prototypes became stereotypes and the guidelines became an obstacle to any architectural innovation. The planning and the design became an exercise of geometry and combinations of the given guidelines and the prototypes. It can hardly be found through such a number of buildings a few interesting architectural solutions.

Copenhagen Denmark

The matter is when a prototype becomes a stereotype, which means that something is reproduced without variations. Even the variations on given prototypes which architects with agony try to apply in their synthesis are limited and usually they are reproduced with dull uniformity

VI. National guidelines, if still have to exist, must be in harmony with each country’s reality. It is crucial to avoid coping, without criticism, norms from other areas. Developing guidelines it has to be considered, apart from specific requirements of the various departments: • Cultural aspects, • environmental conditions, • the climate, • building specifications and local construction techniques • the economy and financial aspects so the level of the lowest cost (usually desirable) must be moderated to a long-term advantage. • Pilot studies

Wiener Allgemeine Krankenhaus Universitatsklinken VAMED Group

Neukolln, Berlin Klaehues + Konig

VII. Where we are today There are traditional transatlantic differences. In Europe the strong role of central and regional governments in healthcare provision tended to encourage tangible and quantifiable progress in medical technology and management sometimes to the detriment of the overall healing experience. Public servants ultimately accountable to elected politicians and taxpayers were reluctant to spent money on such intangibles as good architecture. Other parameters also have been developed as basic factors in hospital design. The idea that environment can perform a healing function by reducing psychological stress was introduced the last two decades. The last decade there is a growing freedom in designing hospitals. Hospital architecture has been returned more than ever in the mainstream of architecture. It seems that this movement started here in USA. New models of health care delivery expressed with new design concepts. The ‘mall’ model, the “hospitality” model, the “residential” models seem to facilitate current health services which are directed more to patient as a consumer of medical services and to market forces. In Norway since the 90’s, as Knut Bergsland said, in a workshop with similar subject than the one we discuss in this session, at EU Health Property Network meeting in Oslo last June, there are no guidance available in designing hospitals. What they do? Architectural competitions, learning from project to project. Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

Krankenhaus, Weimar Germany, Ott Arch

Krankenhaus, Erfurt Germany Rossmann + Harder

Krankenhaus, Aachen Weber+ Brand 4

In Finland, according to information given by our colleague Heli Kotilainen, the general Land Use and Building Act (from 1 January 2000) covers all kind of buildings, also health care facilities. There are a few special chapters for health facilities i.e. the size of a fire compartment, sound insulation, ventilation etc. Regulations, which are based directly on acts, have to be followed, complementary guidelines are not obligatory but local authorities will check them when building permission is applied for. In Germany the whole hospital design is supported and controlled (Gaterman) by DINs and other specifications and the involvement of architects of good background resulted to the creation of a number of pioneered, interesting and advanced hospitals. In Netherlands, as Luub Wessels develops in detail (UIAPHG Seminar Volos 2001), apart from the existence of guidelines, the collaboration between designers and authoritarian public bodies gave the last decade avantgarde health care buildings. That means that there is continuity in the production of hospital buildings. How that can be achieved? Either by central control (e.g. in countries with national health systems) or by architectural firms (specialist expertise) with strong reputation in healthcare design and construction (e.g. Ellerbe Becket in USA). Both directions resulted at the selection of a designer, which is the crucial step. At the same seminar in Oslo Susan Francis speaking about Design Criteria included guidelines, standards, norms but also the impact of the facility: urban and social integration, form and external appearance, character and innovation, internal environment, etc. It seems that these are criteria of good architectural design. In the attempt to bring hospital architecture in the main stream of architecture the support of schools of architecture and interior design and postgraduate courses on healthcare facility planning and design are needed urgently.

Kreiskrankenhaus, Meissen, Germany Worner + Partner

Spandau, Berlin Heinle+Wischer+Freie

Finally norms, standards are seldom revised after a certain period (5 years is considered a maximum). There is a lack of national research in such matters for many reasons especially today.

VIII. Conclusions Medical services are undergoing a dramatic transformation and the designs of healthcare facilities reflect these radical changes. “Patient focused” or “patient centered” facilities, the decentralization of diagnostic and treatments, the coordination of medical team etc is the new concept. But still many design aspects remain the same. • Design for future change has been the critical factor in health care architecture for as long as we can remember. Today the discussion is for more elasticity • Design for value by balancing cost, quality, aesthetics and access still is one of the first principles.

Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

MRI, University Hospital AHEPA, Thessaloniki Vavili+Papathanasiu

Hopital de Zone Yverdon, Suisse Suter + Suter Arch

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The creation of friendly environment, the therapeutic values of the environment and facilities as tool and healer are basic principles incorporated in design Green facilities or sustainable healthcare buildings (materials that are non-toxic, environmentally sustainable solutions, energy conservation, etc) are lately more into consideration and in Europe necessary by laws into public buildings.

There is so much information! ((Nesmith, E., Malkin, J., Torrington Judith, Miller, R & Swensson, E. etc. see bibliography). Where are guidelines for health facilities headed next? This issue is connected to the future of healthcare facilities and services trends and it is not easily addressed. The detailed guidelines on every aspect of design which followed by designers and administrators in public bodies in countries with centralised health care systems and their uniformity is no longer tolerable in decentralised, market orientated healthcare culture (World Architecture: The architecture of the feel-good factor) There are also certain health subjects like deinstitutionalisation of mental health where the solutions must be individual on a basis of basic principles.

Nursing Home, De Stichtse Hof, Laren, Holland 1994 Albetrs & Van Huut Arch

Also guidelines often become an excuse for the lack of architectural inspiration or for a poor architectural result. Today the involvement of inspired architects in the design of hospitals around the world is increasing.

Papanikolaou Hospital, Thessaloniki Vavili-Tsinikas Arch

Even so someone could discuss that standards assure a minimum quality level and guidelines are in need. And the quest for excellence still remains a target. I recommend shortly that guidelines must be: Generic and High Level (General Principles, Operational Issues, Data collection and Lesson sharing) • Flexible (compatible, expandable, adaptable, elastic) • Based upon existing Health Care Building Regulations etc. in each country or region • Built upon criteria that ensure out of the art facilities (good architecture, excellent…) • Developed and Disseminated by responsible bodies e.g. IHF, UIA-PHG, AHA, AAHA, EU Property Network, National Technical Services and other bodies Universities: Architecture, Interior Design, Environmental Psychology, Regional and Urban Planning, Management, Structural - Mechanical and electrical engineering, etc. specialized in Health Care Buildings •

Because the intention is the creation of Out of the Art Health Care Facilities which is our business

Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

Diabalcaniko Hospital, Thessaloniki

Wilhelmina Kinderziekenhuis, Utrecht, Holland

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American Institute of Architects (1993) Guidelines for Construction and Equipment of Hospital and Medical Facilities. Washington, The American Institute of Architects Press Brancon, Gary (1991) The complete Guide to Barrier-Free Housing. Croset USA, Betterway Publ. Bush-Brown, A. & Davis, D. (1992) Hospitable Design for Healthcare and Senior Communities. New York, Van Nostrand Reinhold, pp. 210-213 European Union Health Property Network, fifth meeting, Oslo, June 2003 Gallup Whaley, Joan (1999) Wellness Centers. Wiley series in healthcare and senior living design. Canada, John Wiley & sons. Hans – Evert Gatermann. Management Of Areas In The Process Of Updating And Upgrading General Hospitals, pp. 75-83, ed. Del Nord, R. ed. (1996) Continuity Updating and Upgrading Of Existing Health care facilities: XVIth IPHS Florence. Polistampa Firenze Lockhart, Terence (1981) Housing Adaptations for Disabled People: a guide for architects, occupational therapists, and householders. London, The Architectural Press. Malkin, Jane (1992) Hospital Interior Architecture. New York, Van Nostrand Reinhold Miller, R & Swensson E. (1995) New Directions in Hospital and Healthcare Facility Design. Hong Kong, MacGraw Hill Nesmith, E.L., Health Care Architecture: Design For The Future. Rockport Publishes, Massachusetts Schwarz, B & Brent, Ruth (1999) Aging, Autonomy and Architecture. Baltimore, The Johns Hopkins University Press. Pp. 14 –15 The National Association of Swedish Architects (1970) Guide to construction of social welfare facilities in Sweden during the nineteen sixties. Stockholm The Penguin English Dictionary. Penguin Reference Books, Great Britain Torrington, Judith (1996) Care Rooms For Older People: A Briefing and Design Guide. E & FN SPON, London Vavili, Fani ed. 2001. ‘Design for the Elderly’. UIA-PHG European Seminar, Volos Greece Wislocki, Peter “The architecture of the feel-good factor”, World Architecture No. 47 (June 1996), pp.124-145 Photographs by the writer

Fani Vavili, Dr.Architect, Associate professor, School of Architecture, Faculty of Technology, Aristotle University of Thessaloniki, Greece Address: Al. Michailidi 1, Thessaloniki 54640, Greece Email: [email protected]

Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003

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SHORT CURRICULUM VITAE Dr. FANI VAVILI - TSINIKA Architect (A.U.Th), Master of Arts (U.N.London), Dr. Engineer (A.U.Th.), Associate Professor (A.U.Th.) university address: Department of Architectural Design and Architectural Technology, School of Architecture, Faculty of T...