General hospital building guidelines

5 ARCHITECTURAL CONCEPTS

5.1 Introduction

This chapter gives a few striking examples of hospitals that have either already been built or are in the
process of development. Examples are provided of each distinctive type of building. However, the fact
that these examples have been included here does not mean that a new hospital necessarily has to be
designed on the basis of one of these models. The examples show how concepts such as flexibility,
functional relationships and design were translated in the relevant period or are currently being
translated into the building structure of the hospital.
The following models will be dealt with:
− the Breitfuss model
− the double comb structure
− the arcade model
− the cross structure
− the branched structure
− the linear structure
− the pavilion structure

The building structure of a hospital has undergone a development that shows a decreasing dominance
of the ward block. The treatment and outpatient departments and the flexibility and design of the main
traffic areas have had an increasing impact on the main design of the hospital. Post-war hospital
building in the early decades generated many hospitals with imposing, sometimes monumentally
designed ward blocks. In the eighties, when flexibility became an important concept, more neutrally
designed hospital structures evolved. Subsequent developments show a more internally-oriented design
of the buildings, through the use of covered streets and plazas. Recently developed hospital designs are
characterised on the one hand by more emphasis placed on the design. On the other hand, since
hospitals have been increasingly built in an urban context due to land problems, fitting them into the
urban environment has become an important concept.
General hospital building guidelines

5.2 Breitfuss model

general
A typical feature of the Breitfuss model is that a tall building block with nursing functions is placed above
a flat building block with treatment and outpatient functions. The structure of the building shows a clear
division between the static nursing units in the ward block and the dynamic departments on the lower
two (or three) storeys. The external appearance of the ward block is often of an imposing design due to
its definitive status.

access
In general it may be said that the Breitfuss model produces a compact building with relatively short
walking distances. However, staff and visitors do have to make frequent use of the lifts. The number of
lifts is partly determined by the number of storeys of the ward block. In the case of highrise with around
10 floors, a considerable part of the ward block will be taken up by provisions for vertical traffic (lifts and
(emergency) staircases).
Due to its compact design, this model usually has a clearly recognisable main entrance.

functional relationships
Since the lowrise structure contains all diagnostic and treatment functions, it is possible to create good
spatial relationships with this type of building. Where the medical staff is concerned, the stacking of the
wards can mean that there is a considerable distance between the outpatient unit and the wards.
The Breitfuss model, originally designed according to functional planning of the care provided (outpatient
appointment unit, nursing unit, imaging diagnostics, laboratories, etc.), offers in principle sufficient
possibilities for planning the facilities for care provided on the basis of patient flows or on the basis of the
care process (see § 3.3). The Breitfuss model is less suitable for planning on the basis of target-groups.

flexibility
Where flexibility is concerned, account has only been taken of the possibility of adaptation and
expansion in relation to functions on the lowest floors. No possibilities for expansion or adaptation have
usually been provided for in the ward block. As a result of these limitations in the design, it is more
difficult with this type of building to comply with policy concerning the new style hospital that advocates a
shift from inpatient to outpatient.
General hospital building guidelines

example of Breitfuss model

Location and name of institution The Hague – Leyenburg Hospital
date of completion 1971
number of beds 750 beds
gross floor area 90,000 m²

5.3 Double comb structure

general
The double comb structure is characterised by a traffic zone in the centre from which different building
wings protrude like the teeth of a comb. The building structure is designed like a uniform grid. It
comprises many end walls, the so-called “open ends”, which make it simple to add extensions.

access
Due to the many open ends, the external architecture gives the impression of being unfinished. In
contrast with the Breitfuss model, for example, an overall picture of the hospital is not visible. If located
in the heart of the traffic zone, the main entrance may be hidden between the teeth of the comb.
In the case of large hospitals, this structure can lead to a sprawling design.
General hospital building guidelines

functional relationships
Functions which have to comply with the same requirements are grouped in one wing. From the point of
view of size and technical requirements, the teeth of the comb are geared to the functions to be housed
there. Practical experience has shown that stacking spatially related functions with specific requirements
regarding installations can also be successfully done in one wing. For example, the emergency
department is located on the ground floor, intensive care on the first floor and the operating unit on the
second floor. Other designs may include all laboratories in one wing, plus the pharmacy and the central
sterile supply services unit, or wings with only nursing functions.
The double comb structure is in principle suitable for all three planning models described in § 3.3 with
regard to accommodating the care organisation.

flexibility
The double comb structure was developed at a period when flexibility had become one of the most
important design criteria. Flexibility is guaranteed by extending the teeth of the comb or by extending the
traffic structure by adding a new wing. The basis structure of the hospital remains unchanged after these
extensions.

example of double comb structure

location and name of institution Nieuwegein – St. Antonius Hospital
date of completion 1979
number of beds 579 beds
gross floor area 61,000 m²
General hospital building guidelines

5.4 Arcade structure

general
The arcade hospital emerged as a new model in the early eighties and has been used a number of
times in the Netherlands. In this model, the building elements of the hospital are linked with each other
by a glass-covered arcade for main traffic. Located on both sides of this arcade, on several floors, are
the rooms or internal access routes that look out onto the arcade. In the arcade on the ground floor are a
number of public amenities such as shops and a restaurant.

access
The high arcade is a clear structuring element. The main entrance at one end of the arcade is easily
recognisable. From the arcade, the vertical means of access to the upper floors are clearly visible.

functional relationships
It is evident from the hospitals built in accordance with this model that organisation can take place in
various different ways.
In Waterland Regional Hospital in Purmerend, the functions are located above each other. On the
ground floor are the outpatient clinics, on the first floor the operating department and the laboratories,
and above those a technical floor. The top two storeys house the nursing wards.
In Almere, Flevo Hospital is also based on an arcade model, but in this instance the functions have been
placed behind each other in different parts of the building. The outpatient departments, imaging
diagnostics and the accommodation for management functions are situated near the main entrance. In
the centrally located areas of the building are the operating department, the emergency department,
laboratories and physiotherapy. At the end of the arcade are two building elements containing the
nursing wards.

Maasland Hospital in Sittard, currently at the design stage, will also be built according to the arcade
structure. A section of the building for treatment functions is planned in the heart of the complex, at right
angles to the arcade. Parallel to the arcade on the ground floor and the first floor will come the outpatient
department facilities. Above these, on the top three floors, will be the nursing wards.

The arcade structure is in principle suitable for all three planning models described in § 3.3 with regard
to accommodating the care organisation.

flexibility
In a similar way to the double comb structure, the traffic structure (arcade) can be extended while
retaining the basic structure and new building elements can be added to it. The building elements linked
General hospital building guidelines

to the arcade usually have open ends on the other side that make it simple to add extensions in the
future.

example of arcade structure

location and name of institution Almere – Flevo Hospital
date of completion 1991
number of beds 213 beds
gross floor area 19,000 m²

5.5 Cross structure

general
In the case of this model, two building blocks each in the form of a cross have been linked to each other
so as to create a large covered hall between the two building blocks. The covered hall is the centre of
the building and contains the central facilities.
General hospital building guidelines

access
The main entrance is located in on corner of the covered hall. This plaza is the heart of the structure and
contains the central facilities. The vertical access points in the cross-shaped building blocks are clearly
visible from the plaza. This structure lends itself well to the development of a relatively large hospital
within a compact design.

functional relationships
The best-known hospital based on this model is the Rijnstate Hospital in Arnhem. Virtually all the
nursing wards are housed on the top four storeys of this hospital. The outpatient departments and
treatment & diagnostics units are located on the lower level. Between the upper and lower level is a
technical floor. From the two intersections, a walkway diagonally crosses the central hall at a first floor
level, thereby reducing walking distances. The cross structure is in principle suitable for all three
planning models described in § 3.3 with regard to accommodating the care organisation.

flexibility
The open ends of the cross-shaped building sections can be extended while retaining the basic
structure.

example of cross structure

location and name of institution Arnhem – Rijnstate Hospital
date of completion 1994
number of beds 750 beds
gross floor area 82,000 m²
General hospital building guidelines

5.6 Branched structure

general
Under the heading branched structure, a look will be taken at two completed hospitals where the most
characteristic element of the structure is formed by the number of branches and open ends. This
concerns the Canisius Wilhelmina Hospital in Nijmegen completed in 1992 and the Antonius Hospital in
Sneek completed in 1994. In both of these hospitals, a square central hall forms the heart of the
building.

access
The main entrance is directly linked to the central hall. The central hall is the centre of the structure and
contains amenities such as boutiques and a restaurant. From this central hall the patients and visitors
can gain access to the most important departments of the hospital. The main stairwells and the lifts are
easily accessible from the central hall.

functional relationships
The Canisius-Wilhelmina Hospital in Nijmegen was built according to this design.
With an average of 3 storeys, this hospital is relatively lowrise. The outpatient departments have their
own entrance, but this is located on the same side of the square as the main entrance. Most nursing
wards are located in the branches leading off the square. The operating department and intensive care
are situated on the top floor. The situation and size of the site made it possible to build a relatively
lowrise hospital. This means that all the wards have a pleasant view over the green surroundings.
The Antonius Hospital built in Sneek is also characterised by lowrise building. In this hospital, separate
buildings elements were developed per main function. The services building is located separately so
that this function can respond to future developments. Functions which require a higher building height
have been located on the top floor. This concerns the X-ray and operating departments, physiotherapy,
pharmacy and laboratories.
A branched structure is in principle suitable for all three planning models described in § 3.3 with regard
to accommodating the care organisation.

flexibility
Due to the existence of many open ends, a branched structure possesses by definition sufficient
external flexibility. The following observations may be made regarding flexibility in the Antonius Hospital.
The different function groups have been housed in separate building elements with a construction and
raster size geared to the function group. Supporting outside walls have been used for patient
accommodation, while diagnostic, treatment and service functions have a skeleton structure. Since each
General hospital building guidelines

main function is located at an open end, the possibility of expansion is guaranteed. All beds in the multi-
bed rooms are of equal quality due to the fact that the beds are located by a window. In addition, all
multi-bed rooms can be partitioned into maximum one-bed rooms.

example of branched structure

location and name of institution Sneek – Antonius Hospital

date of completion 1992
number of beds 270 beds
gross floor area 29,000 m²
General hospital building guidelines

example of branched structure

location and name of institution Nijmegen – Canisius-Wilhelmina Hospital
date of completion 1992
number of beds 638 beds
gross floor area 63,000 m²

5.7 Linear structure

general
For the draft plan for Vlietland Hospital in Schiedam, a design has been developed consisting of a single
linear block that can accommodate all hospital functions in accordance with their inter-relationships. The
depth of the block is approximately 22 metres and is designed for the application of a double corridor.
Stairwells and cable and piping shafts have been incorporated in a rational design in the central zone.
General hospital building guidelines

access
The linear block forming the hospital is designed with a number of kinks so that the overall shape
resembles a hairpin. An entrance is located on both sides and opens into a high glass hall that is
wedged between the linear building block. The different lifts and stairwells can be reached from the
central hall. In places where a short link is required for functional purposes, additional glass connection
corridors have been designed between departments located opposite each other. In this way acceptable
walking distances have been achieved.

function relationships
The dimensions of the linear building have been geared to house both outpatient clinics and nursing
wards. On different floors, outpatient departments are located next to nursing wards. In the case of
future bed reductions, wards can easily be converted into outpatient clinic space. This design is fully in
accordance with policy on new style hospitals where a shift from inpatient to outpatient is advocated.

flexibility
There are limitations regarding the external flexibility of the design of Vlietland Hospital on account of the
fact that it only has two open ends and due to the size of the site. Internal flexibility is good, due for
instance to the rational uniform design which makes it possible to interchange functions.
The linear structure is in principle suitable for all three planning models described in § 3.3 with regard to
accommodating the care organisation.
General hospital building guidelines

example of linear structure

location and name of institution Schiedam – Vlietland Hospital
date of completion 2006 (planned)
number of beds 453 beds
gross floor area 48,000 m²

5.8 Pavilion structure

general
During the pre-war years, larger hospitals were built according to the pavilion structure. A cluster of
categorial hospitals was built on the site. This method was abandoned after the war. Today, however,
some designs for large hospitals are returning to the pavilion structure and opting for a plan according to
clinical entities, themes or type of care. An example of this is the design for the Isala Clinics in Zwolle. A
characteristic feature of the pavilion structure is that the spatial facilities that form part of the chosen plan
are grouped together.
General hospital building guidelines

access
The design of the new building for the Isala Clinics comprises four blocks, varying from four to six
storeys. Each block has an atrium. The building blocks will be built on three sides of the existing
complex. Situated beneath the new building blocks is a parking garage from which all four blocks can be
reached. In addition, the main entrance is located between two blocks, passing into a central hall into
which opens an extensive system of corridors providing access to all the building elements. This design
has several different entrances as a result of which extra measures will be necessary from the point of
view of security and surveillance.

functional relationships
The new building will house virtually all patient-related functions, organised per block according to
clinical entity. As you move higher up the building, facilities for outpatients decrease as inpatient facilities
increase.
The pavilion structure is particularly suitable for a plan based on care according to target-groups/clinical
entities.

flexibility
A design based on planning according to clinical entity in one or more building elements has a negative
effect on flexibility. Changes in activities and space between the functional units as a result of
developments in the care sector will be difficult to achieve in the future without a change in the basic
organisation principles.

External flexibility does exist, however, since in this design a number of building elements can be
extended at the ends. Account has also been taken of constructing an extra floor on top of the different
building elements.
General hospital building guidelines

example of pavilion structure

location and name of institution Zwolle – Isala Clinics
date of completion last section 2011 (planned)
number of beds 911 beds
gross floor area 126,000 m²