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by Robert F. Carr NIKA Technologies, Inc. for VA Office of Facilities Management
Last updated: 09-09-2007
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"A functional design can promote skill, economy, conveniences, and comforts; a nonfunctional design can impede activities of all types, detract from quality of care, and raise costs to intolerable levels." ... Hardy and Lammers Hospitals are the most complex of building types. Each hospital is comprised of a wide range of services and functional units. These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental inpatient care or bed-related function. This diversity is reflected in the breadth and specificity of regulations, codes, and oversight that govern hospital construction and operations. Each of the wide-ranging and constantly evolving functions of a hospital, including highly complicated mechanical, electrical, and telecommunications systems, requires specialized knowledge and expertise. No one person can reasonably have complete knowledge, which is why specialized consultants play an important role in hospital planning and design. The functional units within the hospital can have competing needs and priorities. Idealized scenarios and strongly-held individual preferences must be balanced against mandatory requirements, actual functional needs (internal traffic and relationship to other departments), and the financial status of the organization. In addition to the wide range of services that must be accommodated, hospitals must serve and support many different users and stakeholders. Ideally, the design process incorporates direct input from the owner and from key hospital staff early on in the process. The designer also has to be an advocate for the patients, visitors, support staff, volunteers, and suppliers who do not generally have direct input into the design. Good hospital design integrates functional requirements with the human needs of its varied users.
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The basic form of a hospital is, ideally, based on its functions: bed-related inpatient functions outpatient-related functions diagnostic and treatment functions administrative functions service functions (food, supply) research and teaching functions Physical relationships between these functions determine the configuration of the hospital. Certain relationships between the various functions are required—as in the following flow diagrams. These flow diagrams show the movement and communication of people, materials, and waste. Thus the physical configuration of a hospital and its transportation and logistic systems are inextricably intertwined. The transportation systems are influenced by the building configuration, and the configuration is heavily dependent on the transportation systems. The hospital
Flexibility and Expandability Since medical needs and modes of treatment will continue to change. for the efficient handling of food and clean supplies and the removal of waste.) © 2008. if possible—for direct access by outpatients Group or combine functional areas with similar system requirements Provide optimal functional adjacencies. and soiled material Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas. Therapeutic Environment Hospital patients are often fearful and confused and these feelings may impede recovery. recyclables. This system also uses walk-through VAMC Albuquerque. adjacent to "hard spaces" such as clinical laboratories. box conveyors. The VA Hospital Building System also allows vertical expansion without disruptions to floors below. such as locating the surgical intensive care unit adjacent to the operating suite. These adjacencies should be based on a detailed functional program which describes the hospital's intended operations from the standpoint of patients. and plumbing distribution. all hospitals should have certain common attributes. recently reinforced by HIPAA. NM interstitial space between occupied floors for mechanical. other physical - . rather than highly specific ones Be served by modular. but no redundant ones. the form of the typical nursing unit. Compact rectangles. and by making prudent use of multi-purpose spaces Consolidate outpatient functions for more efficient operation—on first floor. designed. and available technology. since it may be repeated many times. modified triangles. is a principal element of the overall configuration. electrical. hospitals should: Follow modular concepts of space planning and layout Use generic room sizes and plans as much as possible. with well planned directions for future expansion.- configuration is also influenced by site restraints and opportunities. This requires careful pre-design programming. and number of beds to a patient room. budget. if properly planned. or budget. for instance positioning "soft spaces" such as administrative departments. and stress-free as possible. size. The chosen solution is heavily dependent on program issues such as organization of the nursing program. All rights reserved. A hospital's interior design should be based on a comprehensive understanding of the facility's mission and its patient profile. comfortable. In a large hospital. Provide an efficient logistics system. surrounding facilities. and gravity or pneumatic chutes. loss of visual acuity. Building Attributes Regardless of their location. manual or automated carts. easily accessed. The characteristics of the patient profile will determine the degree to which the interior design should address aging. pneumatic tubes. For large projects. Efficiency and Cost-Effectiveness An efficient hospital layout should: Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces Allow easy visual supervision of patients by limited staff Include all needed spaces. is to all private rooms. (The trend. which might include elevators. number of beds to a nursing unit. National Institute of Building Sciences. The interior designer plays a major role in this effort to create a therapeutic environment. and bid. such as the VA Hospital Building System. staff. Nursing units today tend to be more compact shapes than the elongated rectangles of the past. climate. this provides continuing adaptability to changing programs and needs. with no first-cost premium. and supplies. or even circles have been used in an attempt to shorten the distance between the nurse station and the patient's bed. New alternatives are generated by new medical needs and new technology. Be open-ended. Every effort should be made to make the hospital stay as unthreatening. and easily modified mechanical and electrical systems Where size and program allow. be designed on a modular system basis.
and finish transitions to avoid dirt-catching and hard-to-clean crevices and joints Adequate and appropriately located housekeeping spaces Special materials. marking glass walls and doors to make their presence obvious Controlled Circulation A hospital is a complex system of interrelated functions requiring constant movement of people and goods. and details for spaces which are to be kept sterile. The new antimicrobial surfaces might be considered for appropriate locations. such as integral cove base. Patients. both inside and out. texture. (As an example. particularly some psychiatric patients (for in depth survey of research related to Color in Healthcare Environments. and abusiveness. keeping in mind that some colors are inappropriate and can interfere with provider assessments of patients' pallor and skin tones. and pattern should all give cues. photo murals of nature scenes are helpful where outdoor views are not available Cross-section showing interstitial space with deck above an occupied floor Designing a "way-finding" process into every project. casework. finishes. and how to get there and return. A patient's sense of competence is encouraged by making spaces easy to find. color. and use without asking for help. Building elements. identify. (See VA Interior Design Manual. and elsewhere wherever possible. This is facilitated by: Appropriate. Cleanliness and Sanitation Hospitals must be easy to clean and maintain.- and mental disabilities. disorient older or impaired patients. be designed so as to be easy to use by the many patients with temporary or permanent handicaps Ensuring grades are flat enough to allow easy movement and sidewalks and corridors are wide enough for two wheelchairs to pass easily Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to dark and light. Much of this circulation should be controlled. see CHER). visitors. what their destination is. Outpatients visiting diagnostic and treatment areas should not travel through inpatient functional areas nor encounter severely ill inpatients Typical outpatient routes should be simple and clearly defined Visitors should have a simple and direct route to each patient nursing unit without penetrating other functional areas Separate patients and visitors from industrial/logistical areas or floors Disclaimer | RSS - . the Uniform Federal Accessibility Standards (UFAS) In addition to meeting minimum requirements of ADA and/or UFAS.) For an in-depth view see WBDG—Therapeutic Environments. and staff all need to know where they are. should: Comply with the minimum requirements of the Americans with Disability Act (ADA) and. if federally funded or owned.) Some important aspects of creating a therapeutic interior are: Using familiar and culturally relevant materials wherever consistent with sanitation and other functional needs Using cheerful and varied colors and textures. Admitting ample natural light wherever feasible and using color-corrected lighting in interior spaces which closely approximates natural daylight Providing views of the outdoors from every patient bed. or agitate patients and staff. as well as artwork and signage. see VA Signage Design Guide. Accessibility All areas. durable finishes for each functional space Careful detailing of such features as doorframes.
food and building maintenance services Aesthetics Aesthetics is closely related to creating a therapeutic environment (homelike. day rooms. and soiled materials should be separated from movement of food and clean supplies. Sustainability Hospitals are large public buildings that have a significant impact on the environment and economy of the surrounding community. for example. Emerging Issues Among the many new developments and trends influencing hospital design are: The decreasing numbers of general practitioners along with the increased use of emergency facilities for primary care The increasing introduction of highly sophisticated diagnostic and treatment technology Requirements to remain operational during and after disasters—see. or because they may be highly visible public buildings with an important role in the public health system. designing hospitals as all-inclusive "wellness centers" Use of hand-held computers and portable diagnostic equipment to allow more mobile. This might require computer alcoves and data ports in corridors outside patient bedrooms. as well as patient accommodations. hospitals have several particular security concerns: Protection of hospital property and assets. both in designing new buildings and retrofitting existing structures New HIPAA (Health Insurance Portability and Accountability Act) regulations address security and privacy of "protected health information" (PHI).- Outflow of trash. Aesthetic considerations include: Increased use of natural light. They are heavy users of energy and water and produce large amounts of waste. decentralized patient care. natural materials.) It is important in enhancing the hospital's public image and is thus an important marketing tool. scale. generously-scaled public spaces Homelike and intimate scale in patient rooms. open. Also see LEED's (Leadership in Energy and Environmental Design) Green Building Rating System for sustainability standards for construction projects. both paper and electronic. including incapacitated patients. Preventative care versus sickness care. and a general shift to computerized patient information of all kinds. Need to balance increasing attention to building security with openness to patients and visitors - .9 of VA's HVAC Design Manual is a good example of hospital energy conservation standards that meet DOE requirements. attractive. consultation rooms. and staff Safe control of violent or unstable patients Vulnerability to damage from terrorism because of proximity to high-vulnerability targets. Section 1. and both should be separated from routes of patients and visitors Transfer of cadavers to and from the morgue should be out of the sight of patients and visitors Dedicated service elevators for deliveries. These regulations put new emphasis on acoustic and visual privacy and may affect location and layout of workstations that handle medical records and other patient information. recyclables. and textures Use of artwork Attention to proportions. Because hospitals place such demands on community resources they are natural candidates for sustainable design. color. A better environment also contributes to better staff morale and patient care. and offices Compatibility of exterior design with its physical surroundings Security and Safety In addition to the general safety concerns of all buildings. VA's Design and Construction Procedure: Natural Disaster Non-Structural Resistive Design State laws requiring earthquake resistance. and detail Bright. including drugs Protection of patients.
However. space planning criteria. and standard details. patient-centered treatment and environments such as promoted by Planetree. Among them are: Department of Veterans Affairs (VA). federal facilities on federal property generally need not comply with state and local codes. which in the past have frequently been based on the three regional model codes. but follow federal regulations. color. and operations for the healthcare industry. The Americans with Disabilities Act (ADA) applies to all public facilities and greatly affects the design of hospitals with its general and specific accessibility requirements. American Nurses Association. by - .- Emergence of palliative care as a specialty in many major medical centers A growing interest in more holistic. Inc. and finishes Design Guide for Improving Hospital Safety in Earthquakes. FEMA. 2nd Edition . Federal agencies that build and operate hospitals have developed detailed standards for the programming. design manuals of technical requirements. Design Details for Health: Making the Most of Interior Design's Healing Potential by Cynthia A. Since hospitals treat patients who are reimbursed under Medicare. and construction of their facilities. they must also meet federal standards. Green Building Council Publications Building Type Basics for Healthcare Facilities . Many of these standards are applicable to the design of non-governmental facilities as well. they must meet standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Like other buildings. and thus that volume often has regulatory status.—Innovative design solutions in key areas such as lighting. Design That Cares: Planning Health Facilities for Patients and Visitors. They are not greatly different from ADA requirements. are now often being based on the model International Building Code (IBC). Relevant Codes and Standards Hospitals are among the most regulated of all building types. To be licensed by the state. American Hospital Association. Many states adopt the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities. 2000. including: Design Guides for planning many different departments and clinics. and Healthcare without Harm to educate healthcare professionals about pollution prevention. Hospitals for a Healthy Environment—A four-member partnership between the Environmental Protection Agency. 1999. design must comply with the individual state licensing regulations. Inc. the federal government and JCAHO refer to the National Fire Protection Association (NFPA) model fire codes. and to be accredited.S. The Uniform Federal Accessibility Standards (UFAS) apply to federal and federally-funded facilities. Green Guide for Health Care™—A best practices guide for healthy and sustainable building design. listed below as a resource. but includes good information on health care statistics and other resources. Floods. American Society of Interior Designers and The University of Minnesota—The first centralized clearinghouse for design and human behavior research on the Web. New York: John Wiley & Sons. Office of Facilities Management Technical Information Library contains many guides and standards. New York: John Wiley & Sons. equipment lists. Society for the Arts in Healthcare (SAH)—National and international advocacy group for the integration of the arts into the healing healthcare environment. State and local codes. construction. particularly in laboratory areas. and High Winds: Providing Protection to People and Buildings. including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101). and locating kitchens and dining areas on inpatient units so family members can prepare food for patients and families to eat together. 2007. U. master specifications. design. room finishes. This might include providing mini-medical libraries and computer terminals so patients can research their conditions and treatments. acoustics. ed. Major Resources Websites American Hospital Association—Information generally focused on financial and organizational issues.. Regulations of the Occupational Safety and Health Administration (OSHA) also affect the design of hospitals. they must follow the local and/or state general building codes. Generally. Stephen Kliment. Leibrock..
ed. Inc. Tools SpaceMedGuide-A Space Planning Guide for Healthcare Facilities—a popular planning tool providing state-of-the-art planning methodologies. Inc. Healthcare Facility Plannning-Thinking Strategically by Cynthia Hayward. 2nd ed. Inc..S. Texas: ACEP (American College of Emergency Physicians) 2000. Rapp. ACHA. 1996. New York: John Wiley & Sons. New York: McGraw-Hill. construction. It serves the health facility operations. Washington. Inc. DC: AIA Press. Equipment. Time Saver Standards for Building Types.. 1997.: Aspen Publishers. 3rd Edition . 1980. Emergency Department Design: A Practical Guide to Planning for the Future by John Huddy and Michael T. DC: U. Health Facilities Review 1992-1993 and subsequent by AIA Committee on Architecture for Health. AIA. Online archives of articles back to 1994. rev. Irving. Md. Hospitals and Health Networks—A monthly journal of the American Hospital Association covering general health care news.. Sarah O. and Clinical Procedures. DC: The American Institute of Architects.. 2001. and Deborah Simmons. Hardy and Lawrence P. Healthcare Design . Myron Grant. Development Study—VA Hospital Building System by Building Systems Development and Stone. Marberry. Guidelines for Design and Construction of Hospitals and Health Care Facilities by AIA Academy of Architecture for Health. Health Admnistration Press and the American College of Healthcare Executives. maintenance. The Planning and Design Process. New York: John Wiley & Sons.- Janet Carpman. and environmental services community. Lammers. Washington. 1977. New York: John Wiley & Sons. Washington. 2005. New York: John Wiley & Sons. with occasional articles on design and construction Hospitals. FAAHC. Modern Healthcare—A weekly journal for healthcare executives with frequent articles on design and construction and an annual design awards program. Government Printing Office. by Jain Malkin. Rockville. by Joseph De Chiara and John Callender. 2001. industry benchmarks. 2002. Health Facilities Management—A monthly journal of the American Hospital Association's Health Forum. Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations by Jain Malkin. and planning tips. 2nd ed. Healthcare Design—A quarterly magazine with design articles and presentations of recent projects Medical and Dental Space Planning: A Comprehensive Guide to Design. 1992. - . Marraccini & Patterson. by Owen B.
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