Professional Documents
Culture Documents
Special thanks go to the BCA Academy and their staff who made the course possible in
the first place. Immense efforts had been put in by them into the logistics and
coordination that had gone into balancing the needs of the academic programme and
the part-time working students, given their diverse background and career demands.
Sincere thanks to the exemplary Khoo Teck Puat Hospital, especially Mr Donald Wai
Wing Tai, for granting visits to and information regarding the Hospital, allowing
invaluable insights into the subject matter discussed in this dissertation.
I am indebted to my company, CPG Consultants Pte Ltd, for the support I have received
from and the inconveniences my colleagues have put up with, in order for me to pursue
the course. Special thanks to Mr Pang Toh Kang, Mr Khew Sin Khoon, Mr Lye Kuan
Loy, Mr Kok King Min for their understanding and support. I would like also to thank
Dr Lee Siew Eang, Mr Glenn Bontigao, Mr Lee Soo Khoong, Mr Lim Lip Chuan, Mr
Jerry Ong, Ms Pauline Tan, Mr Toh Yong Hua, Mr Ng Kim Leong, Mr Soon Chern Yee,
Ms Wong Lee Phing, Mr Yeo Tiong Yeow, Dr Nirmal Kishnani, and Mr Sng Poh Liang
for sharing insights, experience and information regarding the Khoo Teck Puat Hospital
project.
Words cannot express the love, support and sacrifice I have received from my family,
without which it is hard to imagine how I would be able to juggle work, study and
family; a big thank you to you all.
1
Abstract
Contemporary challenges have necessitated the application of sustainable principles and
processes and practices have come to the fore as an important aspect in the delivery of
different parts of the world, including Singapore. Such an integrated approach is backed
extensively in the literature, and as such numerous questions have been raised with
respect to integrated design in practice. These include what is a sustainable design brief;
how do the various stakeholders play out their roles in the integrated design process;
what are the challenges and mindset changes required by the stakeholders in a building
Completed in 2010, the Khoo Teck Puat Hospital in Singapore provided an interesting
case study to study the integrated design process in action. As stated in its design brief, it
aims to be a healthcare building for the future through, first, achieving a visually
pleasing design that sustain with time (Alexandra Hospital, 20051); and second, the
ease and low cost of maintainability resulting from careful overall design and material
selection. Ibid.) The outcome of the design necessitated close collaboration between its
therefore to first, examine how the design of Khoo Teck Puat Hospital has embraced
challenges faced in the integrated design process. This dissertation concludes by making
recommendations that aim to overcome the practical challenges, thereby facilitating the
integrated design process, and hence improving the quality of sustainable building
design.
1 Tender briefing materials by Alexandra Hospital, the forerunner of Khoo Teck Puat Hospital.
2
Declaration
I understand the nature of plagiarism and I am aware of the University s policy on this. I
certify that this dissertation reports original work by me and that all the sources I have
31 January 2012
Signature Date
3
Table of Contents
Acknowledgements ..................................................................................................................................... 1
Abstract .......................................................................................................................................................... 2
Declaration .................................................................................................................................................... 3
Table of Contents.......................................................................................................................................... 4
4
2.2 Benefits of the Integrated Design Approach in Healthcare Architecture ......................... 35
2.3 Essential Elements of the Integrated Design Approach for Healthcare Architecture ..... 39
2.3.2 Mind Set Change: The Need for a Whole-System Mental Model ...................................... 42
Chapter 3.0: Khoo Teck Puat Hospotal: The Case Study ..................................................................... 63
5
3.3.2 The Shared Visions ................................................................................................................... 69
3.4.2 The role of the Architect + IDP Facilitator for Building Design ......................................... 77
3.4.3 The role of the Hospital Planning Team + IDP Facilitator for User Groups ..................... 78
3.5 Discussion KTPH s Visioning, Objective Setting and Team Formation ........................... 81
4.1.10 Hospital Planning Committee Meetings that were held monthly ..................................... 91
6
4.2.3.1 Wind Wall at the Naturally Ventilated Subsized Ward Tower ........................................ 108
4.2.3.2 Detailed Deisgn of Spot Cooling at Roof Terraces: New Air ............................................ 110
4.3 Discussion KTPH s Integrated Design and Iterative Process .......................................... 116
5.1.4 KTPH: Mapping the Attributes of Sustainable Healthcare Architecture and Integrated
5.2 Lessons Learnt on the Practice of Integrated Design from the KTPH Case Study ........ 124
5.2.6 Issues Related to Contractor Appointed via Conventional Approach ............................ 127
7
Appendix VI: Evidence-Based Design Principles ................................................................................ 173
Appendix X: Renewable Energy Systems & Other Innovation Measures ........................................ 188
Appendix XIII: Thermal Comfort Outcome of KTPH s ”ioclimatic and Natural Ventilation
Appendix XIV: Evaluating Human Wellness and Social Sustainability of KTPH .......................... 204
8
List of Tables
Table 1.4 Sustainable design guides and green rating tools for healthcare facilities
Table 2.1 General factors contributing to current fragmentary state of design practice
Table 2.3 Positive attitudes necessary among the integrated design team members
Table 2.6 IDP: Research and workshop activities for healthcare architecture
Table 3.1 Key project team members involved in focus group discussions
Table 3.3 Organizing performance criteria for evaluating the integration of systems
Table 3.4 Framing the sustainability focuses in KTPH s brief for design competition
Table 4.2 Integrated design considerations for façade, thermal comfort and energy usage
Table 4.4 Integrated system design and system efficiency within systems
Table 4.5 Evidence-based evaluation for New “ir spot cooling at outdoor roof terrace
Table 4.6 Comparison between WSIP Process Elements (2007) and KTPH Design Process
Mapping KTPH s integrated design process against the IDP model with
Table 4.7
reference to Figure 4.1 and 4.2
9
List of Figures
Figure 1.4 Comparisons of some green rating systems for sustainable buildings
Figure 2.7 Triple Bottom Line approach goal setting for a project visioning session
Figure 2.9 Iterative process as proposed in Strategies for integrative building design
Figure 2.10 Iteration loops as proposed in Strategies for integrative building design
The traditional team model and an integrated design team model in information
Figure 2.13
exchange
Figure 3.3 Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond
10
List of Figures Cont d
Figure 4.3 Integrated design team organization at the design competition stage
Figure 4.5 Iterative process model during the schematic design phase
Figure 4.6 Landscape plan showing landscaped courtyard as the heart and lung of design
Sketch design for landscaped roof terrace as social space, while providing good
Figure 4.8
shading and insulation to interior spaces below
Landscaped oof terrace at Level 4 where patients, visitors, staff may enjoy
Figure 4.9 moments of solitude or share moments of comfort or grieve; it is also a source of
visual relief from the wards
Figure 4.11 Iterative process model during the schematic design phase
Figure 4.16 Design study 1 for façade shading of the naturally ventilated ward tower
Figure 4.17 Design study 2 for façade shading of the naturally ventilated ward tower
Figure 4.18 Design study 3 for façade shading of the naturally ventilated ward tower
Design developed from Option 3: Fully height louvred façade and light shelf
Figure 4.19
maximizes natural ventilation and daylight
Figure 4.22 Iterative process model during the late design development (DD2) phase
11
List of Figures Cont d
A sample of the air velocity profile across a typical ward at 1.2m height @ open,
Figure 4.24
50% open and closed conditions
A sample of the pressure coefficients chart across the façade of the subsidised
Figure 4.25
ward tower obtained as boundary conditions for the CFD study
Figure 4.26 1:20 Wind tunnel model used for the study
Subsidized ward tower façade showing solar screen to provide shade and wind
Figure 4.27 wall to induce air movement. Greenery is also integrated into the façade to
enhance visual relief
Design drawing showing location of exhaust nozzle integrated into the façade,
Figure 4.28
and the direction of throw to cool the landscaped roof terraces
CFD simulation showing the throw of exhaust nozzle, and the wind speed
Figure 4.30
gradient. A 2m/s wind speed is achieved at the end of the throw
Noise level (dBA) at various distances (m) from the nozzle diffuser. The noise
Figure 4.31 level at landscaped roof terrace at 5m away from nozzle diffuser is 43dBA,
which is equivalent to outdoor ambient sound level
Selection of component: Oscillating nozzle diffusers tested to ISO 5135 1997 and
Figure 4.32 ISO 3741 1999 on sound power level performance to allow for better throw
distribution
Figure 5.3 KTPH Integrated design process: questions framed with the IDP Mental Model
12
Some people prefer to think of health as the
Ted Schettler
sectors.
13
Chapter 1.0 Introduction
Healthcare architecture consists of a wide range of building types, ranging from small
neighbourhood clinics to large hospital complexes; from the general hospitals providing
selected field of medical services and/or research. Large-scale hospitals are arguably one
of the most complex building types, having to accommodate a wide range of functions
and services, for example, outpatient facilities, diagnostic and treatment facilities,
and imaging facilities, administration, food services and housekeeping, etc. The diverse
range of functions and specialized needs require the support of sophisticated and
advanced systems, for example, life support, telecommunication, space comfort and
hygiene, as well as building services that have to be robustly designed (Carr, 2011).
Figure 1.1 The complex relationships between the hospital functions. Source: Carr, R. F. Hospital in
Whole Building Design Guide. Internet WWW: http://www.wbdg.org/design/hospital.php
relation to the network of stakeholders that are involved with large scale hospitals,
14
including patients, doctors, nursing staff, administration staff, servicing staff, visitors,
social and volunteer workers, maintenance crew, suppliers, etc. Conflicting demands
arising out of the myriad of needs and requirements are only to be expected. Good
healthcare design not only seeks to resolve these conflicts, but provide an integrated
3. Therapeutic environments
5. Accessibility
6. Controlled circulation
7. Aesthetic
9. Sustainability
Large-scale healthcare facilities also consume significant resources. To begin with, they
are costly to build; hence significant financial resources are committed to building them,
partnership (PPP) or private finance initiative (PFI). After they are built, not only are
healthcare buildings significant consumers of energy2 and water, they are also producers
objectives and human wellness; not only for patients who seek treatment, but also the
community working in the healthcare built environments (Carr, 2011, 2011; Ray, D,
Betterbricks, Mason, 2006). With the rising global demand for both good quality and
affordable healthcare (World Health Report, 2008), a compelling case must surely be put
forth for all healthcare buildings to be designed and operated in a sustainable manner
2 The US Commercial Building Energy Consumption Survey conducted in 2003 found that
hospital used an average of 250,000 BTU/ft2 (approximately 788.6kW/m2), second only to food
service buildings (Singer, B. C., 2009).
15
1.2 Scope and Objectives
Through a case study of a hospital project in Singapore that was completed in 2010, this
dissertation examines how the integrated design approach had, in practice, contributed
studying and understanding the issues related to sustainable healthcare architecture, and
how integrated design can play an important role in realizing sustainable healthcare
specialized knowledge. Second, the dissertation shall study the integrated design
architecture. Next, the findings shall be compared with what had taken place in practice
through examining the case study of a recently completed hospital in Singapore, namely
the Khoo Teck Puat Hospital (KTPH). Based on the comparative analysis and lessons
2. Identify, as far as possible, the essential elements that comprise the integrated
3. Through documentation study of the KTPH project and interviews with its
project team members, understand how the visioning and briefing process;
process and the design iterations of KTPH took place, to critically appraise the
the KTPH project, the lessons learnt by its team members, and how such lessons
16
1.3 Research Questions
Through these objectives, this research will investigate the benefits associated with the
2. What are the salient elements of the integrated design approach and how are they
design?
4. What are the lessons learnt in the integrated design process in the practice of
healthcare architecture?
5. How can the lessons learnt benefit future practice of integrated design in
healthcare architecture?
the KTPH project, and interview with design/project team members involved in
KTPH project. Materials used in this dissertation are limited to information that
To address these aims, objectives and research questions, the dissertation is structured as
Chapter 1: Introduction
architecture; the scope and objectives of the thesis, research questions and a brief
associated with the design of healthcare architecture, as well as recent developments and
17
Chapter 2: The Integrated Design Approach
the integrated design process. By drawing from various sources, the essential elements of
1. Who are the key stakeholders and why a multi-disciplinary team is needed;
2. The necessary mindset change required for them to be effective in the integrated
design process;
3. The visioning and objective setting process and the sustainable design brief;
This chapter builds upon the work introduced in previous chapters and as such explores
them within the context of the Khoo Teck Puat Hospital (KTPH), a purported sustainable
completed in 2010. As such, Chapter 3 will first provide the background of the KTPH
project, followed by examining how through project visioning, objectives setting, team
formation and organization, the KTPH project had aligned team members mindsets,
attitude and commitment with a common purpose and shared values. This is done
This chapter continues from the previous chapter with the examination of the KTPH
design stages, in the process exploring the contribution from different project team
members, including the client representatives, users, various building professionals, etc;
the integrated design techniques such as small group research and all stakeholders
18
workshops; integrated design tools such as computer building performance simulation
and green rating tools, as well as the challenges encountered in the collaboration process.
Chapter 5: Conclusion
In this chapter, the outcome of the integrated design process, i.e. KTPH as an example of
relationship between integrated design and its outcome. In so doing, it validates the
recommendations on further research areas that will contribute towards improving the
In 2009, the Laurence Berkley National Laboratory (LBNL) produced a report entitled
(Singer and Tschudi, 2009). This report highlighted many of the challenges confronting
healthcare facilities. Amongst these challenges, several stood out as having an important
role in the design of healthcare architecture, and have prompted the discussion set in the
Medical services are often required to operate 24 hours a day, every day of the year. This
leads to high overall energy intensity for hospital architecture. Prescribed operational
needs, life-safety concerns and compliance with codes and standards often demand
building services and equipment to be robust, reliable and with backup. Some of the
3Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to
Improved Energy Efficiency. Lawrence Berkeley National Laboratory. pp 4.
19
Table 1.1 Challenges related to provision of medical services in Singapore
Challenges
1. High Receptacle Loads: To provide good quality medical services, modern medical equipment and
processes are required. Inevitably, energy is required for their operation, resulting in high receptacle
and cooling loads (Singer and Tschudi, 2009). As a reference, BCA-NUS Building Information and
Research Centre rated Singapore office building with total building energy efficiency of
147kWh/year/m2 as excellent , and . kWh/year/m2 or more as poor . Using KTPH as a reference,
if it is designed based on code requirement, its annual consumption is estimated to be
532.11kWh/year/m2 (Toh, Y. H., project mechanical engineer for KTPH, file archive), which is 1.5time
more than the office buildings rated as poor in energy performance.
2. Space Cooling for Tropical Climate: Due to the warm, humid tropical climate in Singapore, and due
to the long operating hours, space cooling becomes one of the main contributing factors for high
energy consumption in healthcare facilities in Singapore. If thermal comfort can be achieved by low-
energy means, significant savings in terms energy consumption and operating expenses can be
achieved. (Lai-Chuah, 2008)
3. Needs for Infection Control: The need for infection control in hospitals, and hence high ventilation
rate, leads to the need for large mechanical systems and high energy demand. Natural ventilation
reduces energy consumption, but poses a question on thermal comfort and whether infection control is
effective. (Infection control association, Singapore)
4. High Energy Costs: As Singapore imports all her energy needs, any measure to reduce energy
consumption be it through conservation, equipment efficiency or process innovation, contributes to
national competitiveness, lowered costs, and better environment by mitigating carbon emission and
combating climate change. The introduction of a national green rating system, the BCA Green Mark
Scheme in January , followed by mandatory compliance in , illustrates Singapore s resolve in
bringing energy consumption in check. (National Energy Agency, Singapore; Building Control
Authority, Singapore)
5. Policy and Cost Control Considerations: For government-funded public hospitals, patients in
different wards either pay medical expenses in full (ward A class), or subsidized between 20%
(maxmimum subsidy in ward B1 class) and 80% (maximum subsidy in ward C class), depending on
their financial means. As all Singaporeans are accessible to enjoy the subsidies, it is therefore essential
that healthcare facilities are designed and operated to provide good quality medical services while
minimizing public expenditure. In this regards, two immediate benefits that sustainable healthcare
architecture may bring is reduced resource consumption and improved wellness for patient and staff.
(Lai-Chuah, 2008; Lim, 2003)
The complex functions in large scale healthcare facilities (Section 1.1) have to be
managed, and its organization and operational structure can likewise be very complex.
The organizational structure and culture of the healthcare organization and/or operator
has a large influence on the design of healthcare architecture. Some of the issues relevant
4Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to
Improved Energy Efficiency, Lawrence Berkeley National Laboratory, p. 8.
20
Table 1.2 Challenges Related to Healthcare Organization, Structure and Culture
Challenges
1. Regulatory and Operational Requirements: As health care is a life-and-death business, some of the
high-energy applications are needed to meet the requirements of medical care, and will not be
compromised. Its operational procedures are also subjected to strict regulatory requirements (Singer
and Tschudi, 2009).
2. Environmental Stewardship: Singapore healthcare sector has a long history of playing the role of
environmental stewardship. For example, Changi General Hospital has a successful programme of
cultivating gardens and vegetables on its roof garden (Verderber, 2010, pp. 162); Alexandra Hospital
“H has embraced the notion of healing gardens by cultivating lush landscaping within the hospital
premise to provide respite for patients, staff and public (FuturArc, 2011 ). As the KTPH management
team comprises largely from the AH team, the values to uphold environmental stewardship was
brought over. Despite the high-energy nature of healthcare operation, the KTPH management team
was resolute in setting high environmental performance target for the new KTPH (Guenther and
Vittori, 2008, p.p. 172-174).
3. Organizational Culture: The budget and decision structures of the usually complex healthcare
organization, as well as its culture, will influence the value-decision such as the willingness (or lack of)
to incur higher capital expenditure to achieve efficient or high-performance building. In addition, the
nature of the healthcare industry may create a risk-averse and conservative culture, and a complex
healthcare organizational structure may be besieged by bureaucracy or partisan-interests, resulting in a
lack of consensus in decision-making. It takes strong courage and management will for healthcare
management and administration to deviate from established practices and approaches to seek
innovative solution to conflicting demands. It also requires from them the ability to mobilize and
organize resources to put in place a project committee and sub-committees, empowered to take actions
and make decisions (Singer and Tschudi, 2009).
Since the introduction of the concept of the triple-bottom-line by John Elkington5, the
concept has been widely understood and accepted as essentially an assessment of social
context may hence be framed along the economic, social and environmental dimensions,
and this three-dimensional framing is adopted for this dissertation. They are briefly
5 The concept of triple bottom line was first coined in 1998 by John Elkington in the book
Cannibals with Forks the Triple ”ottom Line of st Century ”usiness .
6 Guenther and Vittori (2008) has put forth the business case for sustainable healthcare the needs
21
1.6.1 Economic Sustainability
Asia and six globally7. She has one of the lowest infant mortality rates but at the same
time also amongst the lowest in total health care expenditure when compared to
advanced economies in Asia (Gauld et al, 2006, pp. 331), if not the World (Lim, 2003,
with public hospitals providing 80% of the hospital care. The reverse is true for primary
care, with 80% of the services provided by private clinics (Gauld et al, 2006, p. 331).
In addition, the Singapore government places a strong emphasis on fitness and health,
hospitalization stage (treating illness) (Liat, 2009; See Figure 1.2 and 1.3).
To achieve competitive pricing and affordable healthcare costs for patients, hospital
management and administration have to focus on efficiency and cost control measures,
such as lean and efficient operation and staffing, without compromising on the quality of
22
With the assurance of an equitable and sustainable healthcare economic system (Lim,
2003), and no doubt one that will continually to be improved upon to better serve the
evolving society and communities of Singapore9, the next inter-related questions and the
focus of this dissertation, i.e. sustainable healthcare architecture in the Singapore context,
Figure 1.3 Khoo Teck Puat Hospital s holistic Head-To-Toe Lifelong Anticipatory Healthcare of
Whole Person model . Source: Liat, T. L. (2009), Planning for a Hassle Free Hospital.
23
1.6.2 Social Sustainability
following areas:
1. Enhancing the wellness of patients, clinicians and hospital staffs through a stress-
community.
Not only are healthcare facilities merely the premise for the practice of medical science
and technology that provide patient safety and quality patient care, it should also be
theory stems from the fields of environmental psychology (the psycho-social effects of
system), and neuroscience (how the brain perceives architecture) Ibid. , and researches
have shown that provision of therapeutic environment can measurably improve well-
2. Supports the psycho-social and spiritual needs of the patient, family, and staff
(Ibid);
effectiveness (Ibid).
(EBD), a relatively new field of multi-disciplinary study that places importance in using
24
credible data to influence the design process, particularly in its application in healthcare
design and operation (Ulrich, 1984, 1991, 1999, 2000, 2002, 2004, 2006). E”D adds an
being, including light, space, noise, air quality, materials, traffic flow, triage procedures,
(Millard, 2007, p. 267). There are more than 1,000 EBD research studies relating
The built environment should not induce additional stress, but facilitates patients in devoting their
1. energy to healing and recovery, e.g. healing environment; family-centred care environment, effect
of aesthetics, way finding, etc. 1, 2
The built environment should protect and support the well being of the healthcare clinicians and
2.
working staff, e.g. biophilic environments, workplace efficiency, etc. 1, 2
The built environment should not cause harm to the environment and ecology at large, i.e. the
3.
premise of environmental sustainability. 1
4. Design to give patients, visitors and staff contact with nature. 3
5. Design to give patients, staff and visitors views out of buildings. 3
Give all building occupants environmental comfort and control over that comfort, including heat,
6.
light and sound. 3
7. Design to give patients privacy, dignity and company. 3
1 Verderber, 2010
2 McCullough, 2010
3 Lawson (2005), Evidence-Based Design for Healthcare
The rapidly growing body of works in EBD tends to focus on patient-benefits, staff-
and EBD strategies often seem to operate in isolation from each other (Rosenberg,
KTPH case study, it shall be seen how the medical professionals and building
25
professionals had contributed their respective knowledge domains e.g. the notion of
healing garden by the medical professionals, as informed by their practice of the same in
their previous premise, Alexandra Hospital (AH), and the notion of bioclimatic,
Healthy hospitals Walsh in Guenther and Vittori, 2008, p. 390), i.e. hospitals not
merely to treat illness but support and sustain human wellness, may possibly open up its
For the case of KTPH, this relates to the surrounding public housing estates, community
club, Yishun Town Centre and the Yishun Pond and public parks near its vicinity. Over
time, a well-used public place is expected to build up a strong civic identity (Verderber,
healthy living, community gardening, medical social works, etc, promoting community
wellness while fostering environmental awareness. In this regards, KTPH again is used
depletion of resources, many green rating tools have been developed to guide the design
systems are updated. The UK-developed BREEAM, one of the earliest green rating tools
10Tzonis, A.(2006) holds the view that while substantial knowledge advancement had been made
in designing sustainable ecological environments , in terms of sustainable social quality ,
the field to explore is enormous and the task of inquiry is just beginning . He proposed to
explore and discover how decisions about the spatial structure of the environment as a
communicator enable interactions . The evidence-based design as informed by healthcare
architecture and research such as space syntax by Bill Hillier (Hillier, 1999) appear to point
towards this direction.
26
initiated (in 1990; see Figure 1.4), introduced the BREEAM Healthcare in 2008 to cater for
the design of healthcare architecture. The US-developed LEED Healthcare has also been
newly introduced in 2011. It was developed in close collaboration with Green Guide for
healthcare operation. Some other design guides or green rating tools for healthcare
facilities are shown in Table 1.4. The list is not exhaustive. In addition, these tools are
Figure 1.4 Comparisons of some green rating systems for sustainable buildings
Source: Bauer, M., Mösle, P., Schwarz, M. (2010)
27
Table 1.4 Sustainable design guides and green rating tools for healthcare facilities
Situated in the tropics, Singapore needed its own green rating system in order to address
the specific requirements in responding to the climatic, natural, economic, social, cultural
political and national security constraints that Singapore faces (BCA)11. A national green
rating system, namely the BCA Green Mark Scheme, was introduced in January 2005 to
guide the design and operation of green buildings in Singapore. It is a matrix and point
system. Green Mark Version . was adopted for KTPH s design, with Green Mark
Platinum set as the target to achieve. A key question is: is that considered as
environmentally sustainable?
28
neutral, inflection point from degenerating to regenerating health (Ibid., p. 1; Figure
1.5). Anything less than that, even though it may be Green or High Performance ,
simply means that it is better than conventional practice but still causes degeneration to
the environment, albeit to a lesser degree. A restorative design or system is one that is
able to restore the capability of local natural systems to a healthy state of self
organization (Ibid., p. 2), and Regenerative design or system are an integral part of
the process of life in that place (Ibid., p. 2). In a regenerative system, people, built-form
and natural systems enter a healthy state of co-evolution. In this sense, not only is
sustainable architecture one that seeks to restore human wellness in the social
dimension, but as part of the natural systems, one that seeks to restore and regenerate
29
Some have therefore promoted the notion of restorative environmental design Kellert,
2004; Birkeland, 2002), by extending the concept of ecological health to include humans
in the ecological equation Kellert, 2004, p. 3). Architecturally, this includes embracing
nature in the built environment, which complements the inter-related notion of biophilic
architecture (Ibid., Wilson, 1984; Kellert et al, 1993). The notion of biophilia premised on
human s innate affinity with nature and living things, promoting human wellness and
regenerating the natural systems. Set out to embrace nature for its therapeutic properties,
KTPH again provides a case study demonstrating attempts in fostering natural systems.
By taking into account the various sustainability dimensions in the Singapore healthcare
context (Section 1.6.1 on economic dimension, Section 1.6.2 on social dimension, Section
as an integrated solution that addresses all three dimensions in a holistic manner (Figure
Eco-Design
Biophilic Built Environment
Built environment that integrates with
natural and ecological systems
Environmental
Sustainability
Social Economic
Sustainability Sustainability
30
1.6). As proposed, KTPH that was built in 2010 provides a case study for the examination
immediate question is: what are the process challenges to be overcome before one is able
next section.
Section 1.5 of this dissertation presents the key challenges confronted in healthcare
architecture, especially in large scale hospitals. These challenges are rooted in the
It is followed by Section 1.6, which presents the opportunities in the Singapore context
green building design from the building professions; and natural systems from
2. The various disciplines need to propose and agree on the specific objectives and
doing, they must resolve any conflict between these objectives and requirements,
by asking the following questions: Are there trade-offs between these objectives?
3. After the design objectives and requirements have been determined, a design
31
require knowledge input from different professional disciplines, a team-based,
approach, and some sources have advocated that it is particularly useful for the design
of healthcare facilities (Guenther and Vittori, 2008, LEED 2009 for Healthcare, Green
Guide for Health Care v2.2). The relevance of integrated design for healthcare
architecture is examined in the next chapter. It starts by defining the integrated design
32
“n integrated design process creates
Bill Reed
project at a time.
Alex Zimmerman
33
Chapter 2.0 The Integrated Design Approach
Chapter 1 presents the challenges in the design of sustainable healthcare architecture, in
which knowledge inputs from the different disciplines need to be integrated in a holistic
integrated design approach. In this chapter, by drawing from literature, the following are
presented:
2.2);
The Roadmap for the Integrated Design Process defines the integrated design
Using the term integrative design , group and ”ill defines it as one that optimizes the
interrelationships between all the elements and entities associated with building projects
in the service of efficient and effective use of resources 7group)12. Known also as the
whole building design process , Whole ”uilding Design Guide website defines
integrated design as one that includes the active and continuing participation of users,
code officials, building technologists, cost consultants, civil engineers, mechanical and
many specialized fields. 13 This dissertation takes the position that the above definitions
refer to the same subject matter by taking slightly different perspectives; but their intent
and purpose are the same. Hence, for simplicity, the term integrated design ,
34
integrative design and whole-system design as defined by various literature sources
are referred to in this dissertation by the term integrated design . Summarizing from
these sources, the definitions of the integrated design approach for the purpose of this
considerations;
sustainability objectives.
In chapter 6 Design Process of the book Sustainable Healthcare Architecture, Guenther and
Vittori (2008) give a comprehensive account relating the benefits of the integrated design
supplementary support from other literature sources, the views are briefly explained in
5. The second outcome is the building up of an ongoing learning culture within the
35
2.2.1 Increasing Scale & Complexity
Healthcare facilities are confronted with increasing scale and project complexity,
considerations, design & construction process, etc (Ibid., p 129). Some of these
The advancement in modern technology and materials has led to ever-increasing level of
sophistication and complexity in modern buildings, resulting in the need for more
the building professionals have a tendency to perform their work with minimal
shortest possible time duration (7group and Reed, 2009; Table 2.1). Such traditional
siloed and linear project delivery process is neither able to nor able to optimized
Table 2.1 General factors contributing to current fragmentary state of design practice (7group
and Reed, 2009)
S/No. Factors
1. Specialization: Rapid advancement of technology and new materials has led to ever-increasing
levels of sophistication and complexity in modern buildings, resulting in the need for more
specialists in building projects, many of them responsible for and involved in only a part of the
project or a specialized system. Furthermore, in the globalised world, it is not uncommon that
many of the specialists are from a different geographical location, and practising in a different
cultural and legislative context. The focus on each specialist s own works often leads to a lack of
concern for or connection to others work. In addition, due to the disconnectedness, they do not
participate in the problem selection stage of the early design process, leading to missed-
opportunities (p. 9-11).
2. Siloed optimization : The fast-pace demand of modern lifestyles tends to result in highly efficient
specialists, who are skilled in optimizing the design of their own disciplines in isolation. This is
often carried out with minimum contact between the project team members. As building systems
often require input from different disciplines, such silo-mentality negates the opportunities to
optimize within a building system; far less between building systems (p. 9-11).
3. Disconnect between design and construction professionals: The design intended to be built is
represented in design documentation. The first opportunity for the builders to read the design
documentation is usually during the tender process. Soon after the award of tender, the
construction starts, and there is effectively very little time given to the contractor to understand the
design. The construction process more closely resembles assembly than integration…we often
find redundancies, unnecessary costs, and a great deal of wasted time and effort. p.
36
building performance, nor keep pace with rapid innovation in medical sciences and
technologies (Guenther and Vittori, 2008, p. 129), as they do not invest time in learning.
code-compliant norms (7group and Reed, 2009, p. 9 11; see also Table 2.1).
The alternative design process, i.e. the purported integrated design process is one that
seeks to:
2008, p. 130; Yudelson, 2009, p. 53; LEED for Healthcare 2009, p. 89, Green Guide
2. Establish new, inclusive and collaborative mindset (Guenther and Vittori, 2008,
3. Set bold vision and objectives (Guenther and Vittori, 2008, pp. 130; Yudelson,
2009, p. 46);
4. Employ iterative design process through group workshops and design charettes
(Guenther and Vittori, 2008, pp. 130; 7group and Bill, 2009, pp. 68);
feedback loops so as to inform future design (7group and Bill, 2009, p. 312-313).
A comparison between the integrated design process and the conventional design
process, as collated and summarized from various literature sources is shown in Table
2.2.
37
Table 2.2 Comparison between Integrated and Conventional Design Processes
References:
1 Busby Perkins+Will and Stantec Consulting, (2007). Roadmap for the Integrated Design Process. p. 8.
2 7Group, Reed, B., (2009). The Integrative Design Guide to Green Building: Redefining the Practice of Sustainability. p. 9.
3 Yudelson, J., (2009). Green Building through Integrated Design. p. 46.
4 ANSI MTS 1.0 WSIP Guide, (2007). Whole System Integrated Process Guide. p. 3-4.
To Guenther and Vittori (2008), the main intended outcome of the integrated design
planning, envelope design, systems design and material selection in a holistic manner,
Bokalders and Block, 2010), providing positive outcomes to the community and human
Section 1.6.4, the notion of sustainable healthcare architecture in the Singapore context is
worthy to be revisited in Section 2.3.5, after the integrated design approach has been
presented.
38
2.2.5 Learning Organization
Guenther and Vittori (2008) further suggested that healthcare organizations should
indeed strive to be learning organizations, imbue with a culture that values continual
learning and improvement, and engages all its members in doing so. By engaging the
project vision and goals into the architectural design (ibid., p. 130), achieving synergy
sustainable healthcare architecture, the next section discusses the essential elements of
This section expands on the integrated design approach for healthcare architecture by
1. The multi-disciplinary project team and the expertise they need to bring to bear
2. Mindset change that is required among the project team members in order to be
3. The integrated design process: What the project team members need to do right
(Section 2.3.3);
4. Tools and techniques: What are the tools and techniques that support integrated
5. The integrated design product: What are the expected outcomes of integrated
39
2.3.1 The Multi-Disciplinary Project Team
The integrated design approach advocates at bringing together, at an early stage, all key
stakeholders, e.g. owner, management, building designers (e.g. architects, civil &
consultants (e.g. cost, lighting, acoustic, façade, green design, etc), builders, users,
operators, and perhaps even community representatives, to identify common goals and
objectives of the hospital project (Guenther and Vittori, 2008). This is because no one
party has all the knowledge of the design problems, especially for a large, complex
hospital. Without a proper brief formulation process at an early stage, the opportunity
for deriving a holistic, integrated solution will quickly diminish as project time is
A suggested list of members for an integrated project team is given in LEED 2009 for
Healthcare (Figure 2.1). The organization of the team is discussed in Section 2.3.3.1.
in the team. For the case of sustainable healthcare facilities, it is essential to include in the
project team the representatives from the medical professionals, e.g. clinicians, nursing
40
leaders and operational managers. Not only are they expected to share knowledge and
experience, as a result providing insights on how work in the healthcare facilities is done
today, they are expected to think through how work can be done better, hence providing
foresight for the next 10 to 15 years (Pille and Richter, in McCullough, 2010, p. 16, 119).
After the myriad of clinical and operational requirements had been identified, they need
to be put together spatially and systemically, and resolved with other building
requirements.
problem solvers Williams, , p. , are the most suited in leading the team of
problems to represent the range of design problems, issues or constraints that building
designers need to grapple with (Figure 2.2). They include design problems generated
from the designers own knowledge, as well as those from building regulations
These problems may be internal, e.g. designer s own set of values or external, e.g. fire
further requirements are imposed from: Purpose of the building project (radical);
(practical); visual organization e.g. massing, proportion, texture, colour, etc; and the
14In the case of KTPH, clients are represented by the hospital management (Alexandra Health)
and the government (Ministry of Health), which is the policy maker and funding agency. The
users include the clinicians, nursing leaders, laboratory leaders, office administrators, operational
managers, etc.
41
Figure . ”ryan Lawson s model of design problems or constraints
Source: Lawson, B. (2005). How Designers Think: The Design Process Demystified, p 106.
The whole cluster of design problems requires holistic solution finding with design
iteration involving different experts, balancing one requirement versus another, in the
process seeking to find synergies between these requirements. This is the premise of
2.3.2 Mind Set Change: The Need for a Whole-System Mental Model
Before moving on to the presentation of the integrated design process and tools, it is
important to emphasize on the need for mindset change among the integrated design
team members (Reed, Todd and Malin, 2005; Reed in Guenther and Vittori, 2008, pp.
132). At this juncture, it is useful to refer to the model developed by Bill Reed and Barbra
15 Lawson has also put it that, design inevitably involves subjective value judgement , p.
124), and as three-dimensional problem solvers in control of the primary design generator
(ibid), the architect plays a highly influential role in perpetuating the values in the design
solution, but it also comes with heavy responsibilities in the success of the integrated design
process, e.g. to adopt an open mind and listen to views (and values) offered by other team
members it demands that architects fundamentally alter their role. ”ut giving up control goes
against everything architects are taught Deutsch, , p. . This may impose hurdles in the
practice of integrated design, so a critical self-examination in architectural education and practice
is warranted.
42
Batshalom (Reed, Todd and Malin, 2005; Guenther and Vittori, 2008, pp. 131-135) as
shown in Figure 2.3. It clarifies the relationship between mental model (mindset, attitude
and will), process (design, iterative analysis, workshop, charrette), tools (green rating
product).
The siloed and linear traditional mode of thinking and design approach needs to be
replaced by a mental model centred on whole-system thinking (Reed, Todd and Malin,
2005). It is premised on seeing not only the parts, but the whole; and not only what the
system does, but what is the purpose of the system, or how does the system contributes
Even with the multi-disciplinary project team in place, without the right team attitude,
encountered (Figure 2.4). Many integrated design guides hence advocate the needs to
design team members. These attitude attributes tend to foster a group dynamics that
allows the design team to generate design outcomes beyond the abilities of the
43
collective individual talents Lawson, , p. . “ summary of these attributes from
Table 2.3 Positive attitudes necessary among the integrated design team members
S/No. Factors
1. Clear leadership ; 2
References:
1 Busby Perkins+Will and Stantec Consulting, (2007). Roadmap for the Integrated Design Process. p. 9.
2 7Group and Reed, (2009). The Integrative Design Guide to Green Building: Redefining the Practice of Sustainability. p. 30-
31.
The right mindset needs to be supported by the right process. The Whole Systems
Integrated Process (WSIP, 2007) as recommended in LEED 2009 for Healthcare (p. 93) is
used in this dissertation as the IDP reference, supported and complimented by other
literature references as and when necessary. The WSIP (2007) is intended as a standard
44
guideline to support the building industry in the practice of integrative design p. 1)16,
and its purpose is to provide a common reference for all practitioners architects,
and so on) in support of process changes needed to effectively realize cost savings,
environment for all living systems human, other biological, and earth systems. Ibid.,
p. 1) Based on WSIP (2007, p. 8), the process stages in IDP may be categorized into six
Stage Elements
1. Team Formation Fully engage Client in the design decision process.
“ssemble the right team.
Key attributes in team formation is teachable attitude members come on board
not as experts but co-learners.
2. Visioning “lign team around basic “spirations, a Core Purpose, and Core Values.
3. Objectives Setting Identify key systems to be addressed that will most benefit the environment
and project
Commit to specific measurable goals for key systems
Compile into a Sustainable design brief
Key attributes in objective setting is to involve all participants, including the
main financial decision maker, not unempowered representative. Also, identify
champions for the objectives and issues.
4. Design Iteration Optimization of the design of systems
Key attributes in objective setting is to understand and make best use of key
systems in relationship to each other, to the goals, and to the core purpose , and
Iterate ideas and systems relationships among team with all participants,
including the main financial decision maker.
5. Construction & Follow through during the Construction Process.
Commissioning Commission the project.
6. Post-occupancy Maintain the system.
Feedback Loops Measure performance and respond to feedback - adjust key aspects of the
system accordingly.
16Whole System Integration Process (WSIP, 2007), The Institute for Market Transformation to
Sustainability, Washington.
45
2.3.3.1 Team Formation and Organization
The need for multi-disciplinary team formation has been covered in Section 2.3.1.
However, the team structure and organization and how effective each team members
play out their role is very important in driving the process forward. The Road Map for
the Integrated Design Process IDP Road Map; Busby Perkins+Will and Stantec
Consulting, 2007) proposes that the integrated design team (IDT) be formed as early as
1. Client: The client takes an active role throughout the design process.
is present.
3. Team Leader: A team leader (champion) is responsible for motivating the team
5. Core Project Team: The core group of team members remains intact for the
The multi-disciplinary core project team is responsible to collaborate and drive the
project forward, as well as to identify and bring in additional team members with
relevant expertise that support the project (Ibid. p. 15-17). Table 2.5 provides a basic
summary of the recommended core project team members, additional members and
description of their expected roles. A more detailed role of the various members
To facilitate the collaborative spirit among the team members, the IDP Roadmap
recommends two additional roles not usually found in traditional team organization:
1. Facilitator: The IDP Facilitator manages the integrated design process. He/she
may be one of the project core team members, e.g. project manager or architect, or
it may comprise a team, but the most important attribute skill sets they bring to
46
bear are in facilitation and group dynamics, and they must have a good
knowledge of the integrated design process IDP) (IDP Roadmap 2007, p. 17).
2. Champion: The Champion is aligned with the vision of the project and is
someone who is able to empower the team, understand the political and
organizational barriers and is able to overcome them. The Champion may also be
A comparison between the conventional team organization and the IDP team
organization is shown in Figures 2.5 and 2.6 (IDP Road Map, 2007, p. 18).
Table 2.5 Core Integrated Project Team Members (IDP Road Map, 2007, p.15-17, Appendix B)
47
Table 2.6 Additional Integrated Project Team Members (IDP Road Map, 2007, p.15-17,
Appendix B)
Additional Member
1. Ecologist 9. Commissioning agent
2. Occupants or users representatives 10. Marketing expert
3. Building program representative 11. Surveyor
4. Planning/regulatory/code approvals agencies 12. Valuation/appraisal professional
reps
5. Interior designer/ materials consultant 13. Controls specialist
6. Lighting or daylighting specialist 14. Other experts as required (e.g., natural
ventilation, thermal storage, acoustic)
7. Building program representative 15. Academics and/or students with knowledge of
a relevant subject
8. Soils or geotechnical engineer 16. Members of the community who are affected
by the project.
48
2.3.3.2 Visioning
The visioning exercise provides the opportunity to align team members mindsets,
attitude (as discussed in Section 2.3.2) and will or commitment to a common purpose
and shared values. For healthcare organizations, this also provides the opportunity to
align its long-term health vision and mission to serve as the navigation beacons to guide
Visions need to be supported by specific design objectives establish early in the project.
To achieve balanced objectives, one recommendation is to guide the objective and goal
Figure 2.7 Triple Bottom Line approach goal setting for a project visioning session
Source: Yudelson (2009). Green Building through Integrated Design. p. 147.
For healthcare project, this may include setting objectives such as:
49
1. Economic sustainability: Setting high-performance goals that raise the bar or
challenge the status quo, by specifying measurable targets such as reduce energy
The vision and objectives shall not, however, become prescriptive, or worse, describe the
solution, in so doing giving little room for designers to seek creative solution (Lawson
Design iteration is a key feature in any IDP methodologies. WSIP (2007) emphasized the
parties (represented by the coloured bars in Figure 2.8) and team charrettes or workshop
sessions participated by key stakeholders (represented by the blue dots in Figure 2.8).
These are denoted as R1 to R4 and W1 to W7, and their iterative activities are
W1 W2 W3 W4 W5 W6 W7
R1 R2 R3 R4
50
Table 2.7 IDP: Research and workshop activities for healthcare architecture
Stage Elements
Preliminary research, e.g. identify base condition, context of project, and
R1: Research/
sustainability opportunities; project programming; preliminary climatic
Analysis #1
studies, etc.
W1: Workshop/ Visioning exercise involving all key stakeholders
Charrette #1 Goal Setting and alignment of purpose/objectives among all participants.
Continue research, e.g. establish comparative benchmarks, envelope and
shading study, energy modeling, water management studies, clinical and
R2: Research/
operational workflow studies, space planning, circulation analysis,
Analysis #2
investigation of structural system, life cycle cost studies, etc.
Test initial concept for feasibility
Generate or iterate concept design or early schematic design through
W2: Workshop/ charrettes.
Charrette #2 Review integrative cost bundling studies.
Confirm with client the alignment of project with vision and objectives.
Schematic design “lignment of research and integration of design.
Iterate design at more detailed levels, optimize system designs.
R3: Research/
Review integrative cost bundling studies.
Use metric, benchmark and green rating tools to test design.
Analysis #3
51
In Strategies for integrative building design , van der Aa, Heiselberg and Perino (2011)
proposed a more detailed iterative process during the schematic design (SD) phase and
design development (DD) phase. They proposed that design iteration shall progress
from concept design phase to system design phase, and eventually to component
design phase (Figure 2.9). In the concept design phase, broad strategies are considered,
including response to local climate (Ibid.). For sustainable healthcare architecture, other
requirements, and opportunities for ecological integration with the surrounding. In the
system design phase, specific architectural and technical solutions are proposed,
supported by design calculations and simulations. In the process, the design team
members should seek opportunity for design integration of systems (Ibid.). The
which seeks to confirm the system design, before proceeding to the design and selection
Research/Analysis Workshops/
Decisions
SD
DD
Figure 2.9 Iterative processes as proposed in Strategies for integrative building design van der
Aa, Heiselberg and Perino, 2011). Text in red added for referencing with WSIP (2007).
van der Aa, Heiselberg and Perino (2011) highlight that the integrated design process is
of design alternatives and optimization…and taking into consideration input from other
52
specialists, influences from context and society that provide possibilities and/or
limitations to design solutions as well as evaluates the solutions according to the design
goals and criteria ibid., p. . There are many alternative theories regarding the
iteration loops or process, which are presented in Appendix II. The position taken in this
, there is no infallibly good way of designing. In design the solution is not just the
logical outcome of the problem, and there is therefore no sequence of operations which
Figure 2.10 Iteration loops as proposed in Strategies for integrative building design van der
Aa, Heiselberg and Perino, . [This author is of the view that Coal in the diagramme is a
typological error and show read as Goal instead].
Both the Integrated design process (WSIP, 2007; Figure 2.8) and the Iterative process (van
der Aa, Heiselberg and Perino, 2011; Figure 2.9) are used as models to examine the
Depending on the type of contract procurement method, the contractor may join the
project team earlier or only at this stage. Again, an alignment between client, design
53
2.3.3.6 Post Occupancy Feedback Loops
After proper handing over of building and facilities, the operations and maintenance of
the facilities are carried out by trained personnel, based on sustainable principles.
Building monitoring systems begin to measure and trend building performance, and
usage. The owner, design team continue to receive feedback on the systems data
(building, energy, water, landscape, habitat, etc), so that the information gained can be
studied, analyzed and form evidence-based studies to inform future design. This
attribute of a continuous learning culture in the integrated design process augurs well
earlier in Section 2.2 and 2.2.5, particularly in studies relating environment to human
wellness.
Before moving on to discuss about the IDP tools and techniques, a comparison between
the IDP and linear design process (LDP) will provide clarity on the difference between
IDP and LDP. With reference to Figure 2.11, the IDP is contrasted against LDP as follows
(Figure 2.11):
1. Activities are front loaded for IDP, and the reverse for LDP.
development (DD) and construction documentation (CD) for IDP; short SD, long
research are held from the start, gradually tapering off near DD; for LDP,
activities start slow but begins to peak at DD, and probably continues through
4. Continuous value engineering (VE) for IDP, sporadic and intense during bid and
54
5. VE for IDP focuses on system synergy, VE for LDP focuses on eliminating
Figure 2.11 Integrative design process versus linear design process. Source: WSIP (2007)
The integrated design process needs to be facilitated by design tools to inform team-
collaboration. These are briefly presented in the sub-sections 2.2.4.1 and 2.2.4.2.
During the integrated design process, various tools may be utilized to permit informed
decision-making. Many of such tools are becoming widely available (Reed, Todd and
Malin, 2005). Some of the tools relevant for healthcare architecture include:
1. Green rating tools, e.g. BREEAM Healthcare, LEED for Healthcare, Green Mark,
etc.
2. Green design guides, e.g. Green Guide for Health (GGHC), Practice Greenhealth,
etc.
55
3. Scale modeling tools, e.g. wind tunnel test;
5. Life cycle costing and Life cycle assessment tools, e.g. Building for Environmental
Green rating tools (GRT) had been briefly discussed in 1.6.3. Those tailored for
healthcare facilities are usually jointly developed and endorsed by both building and
GRT or metrics are primarily used as building performance metric to set design
objectives for the project (WSIP, 2007), but may also be used as systematic frameworks to
guide and align the project team members (IDP Roadmap, 2007). GRT provide a
commonly accepted standard for assessing green buildings in their respective home
rating system also allows building design parameters and best practices to be captured
in a central database (Ibid., 2009). Over time this is a form of learning loops to allow the
building design. Other forms of tools such as Green design guides e.g. GGHC are
practices in which designers, owners, and operators can use to guide and evaluate their
Scale and computer modeling tools allow the building performance of different design
made (IDP Roadmap, p. 15). Currently, the common modeling tools used in the design
process includes climatic, sun path and shading analysis software (Autodesk Ecotect;
Integrated Environmental Solutions, etc); wind tunnel and CFD software that simulates
air buoyancy and air movement which is useful when strategies involving natural
56
integrated design process, as it allows the different contributing factors that affect energy
which credit points to aptly applied energy modeling and other forms of simulations
(BCA).17
Life cycle cost (LCC) provides consideration of cost based on whole-life principle, which
maintenance, operation and disposal (Riggs, 1982). The use of LCC tools facilitate the
IDP project team by allowing decisions to be made based on the long-term cost impact of
each iteration option. The parameters of LCC need to be defined, e.g. whether it
considers only building operation, or also takes into account human productivity (Fuller,
2010). Life cycle assessment (LCA) tools such as ISO 14040 (2006) assesses environmental
recycling (Ibid.).
parametric properties that may be manipulated in the design process (Krygiel and Nies,
2008). What is perhaps more important is that BIM allows a central, shared virtual model
to be accessible by all the integrated design team members. Each team member is able to
contribute by adding layers of information to the model, and their effects on other team
members layers of information becomes apparent in the virtual model (Ibid.; Figure
57
having separate CAD files. A more profound impact it brings to the building industry is
that the new paradigm of BIM workflow mirrors the integrated design paradigm (Fig
presentation of BIM and its benefits are presented in Appendix III). Due to its benefits
and huge potentials in reinventing the construction industry, BIM is actively promoted
BIM adoption in Singapore gathers speed only after 2008, and unfortunately KTPH did
Figure 2.12 The integrated design model. Source: Krygiel and Nies, 2008, p. 37
Figure 2.13 The traditional team model and an integrated design team model in information
exchange. Source: Krygiel and Nies, 2008, p. 61
58
2.3.4.2 Integrated Design Techniques
change, such as (7Group et al, 2009; Busby Perkins+Will, 2007; WSIP, 2007; Roadmap,
2007)18:
quality.
3. Good communication/dialogue/conversation/narration/negotiation.
The integrated design approach explicitly promotes the often overlooked aspect of
design as a social, collective process, in which the rapport between group members can
be as significant as their ideas (Lawson, 2005, p. 240). Since large scale and complex
healthcare projects often require a sizable building design team with support from
specialists and non-design professionals e.g. clinicians, nursing leaders and operation
managers, social skills and group dynamics among the team members are as crucial as
their professional skills and knowledge in ensuring project success. The adoption of new
In addition, some have suggested that in the creative process, group dynamics has a
distinct advantage over the individual. In How Designers Think: The Design Process
Demystified, Lawson (2005) described in the design of St Mary Hospital, how Tim Burton
assembled a group comprising representatives from three client bodies and consultants,
and over a three-day intensive design process, led the group to agree on the main
18Some IDP literature provides very specific guides on techniques, e.g. effective facilitation
(Roadmap, 2007, p.p. 21-22). Effectiveness of these techniques may be subjected to cultural
influences, and is not the focus of this dissertation.
59
heading of the brief, identified three basic design strategies and selected one for further
development including rough costings (Ibid., p. 241). The selected scheme became the
In postulating the future roles of the designers (not limited to building designers, but
Lawson stated that one plausible outcome is designers remain professionally qualified
specialists but try to involve the users of their designs in the process (Ibid., p. 30) In
such a world, in which designers no longer have a monopoly of design knowledge, the
participatory approach allows designers to stay relevant and engaged with the
stakeholders (who may hire design and building professionals to represent them), by
offering specialist skills to identify the crucial aspects of the problem, make them
explicit, and suggest alternative courses of action for comment by the non-designer
participants (Ibid., p. 30). The evolution of such a role for designers will be coupled
with the development of new processes, e.g. IDP and new tools, e.g. building
holistic manner (Figure 1.5). In Section 2.2.4, it is further put forward that the integrated
integrating whole-building system design that optimizes building site layout, envelope
design, system design and material selection in a holistic manner, reducing initial cost
60
Summarizing from the discussion so far, in the Singapore context, the relationship
Eco-Design
Biophilic Built Environment
Built environment that integrates with
natural and ecological systems
Environmental Sustainability
Design Solution
3. Sustainable Healthcare
Architecture as a holistic, Environmental
Sustainability
integrated design
outcome/solution
Social Economic
Sustainability Sustainability
61
2.4 Discussion: The Aspects of Integrated Design Process to be
Investigated
In Section 2.1 of this chapter, by drawing from literature, the definition of integrated
design approach has been defined. It is then followed by Section 2.2, in which its
relevance and benefits to the design of healthcare architecture is presented. Section 2.3
presents the essential elements of the integrated design approach (Figure 2.3). Following
that, Section 2.3.3 focuses on the integrated design process, which contains the following
important stages, with stage 1 to 4 being the focused study areas of this dissertation:
In summary, this chapter presents a model of the integrated design approach in theory.
Most of the IDP literature acknowledged that the IDP model needs to be tailored to real-
world constraints faced in practice (WSIP, 2007; IDP Roadmap, 2007). KTPH, purported
model. The comparison will be carried out in the next two chapters, starting with
Chapter 3: Briefing introduction of the KTPH project, followed by its visioning, objective
62
I posed the challenge to the “H rebuilding team build
hassle-free hospital.
the hospital.
Stephen Verderber
63
Chapter 3.0 Khoo Teck Puat Hospotal: The Case Study
Section 2.3.3 provides a theoretical model of the integrated design process. This chapter
compares the visioning and objective setting process between theory and in practice by
using KTPH as a reference. It begins by providing the basic background of the KTPH
exercises. This is done through a comprehensive study of the literature and project
document, as well as through interviews with the key project team members involved.
3.1 Background
As of 2011, there are eight public hospitals in Singapore, with Khoo Teck Puat Khoo Teck
Puat Hospital (KTPH) being the latest addition. The KTPH is a 550 bed acute care public
hospital offering a comprehensive range of medical and health services, situated in the
North to serve more than 700,000 residents in the region. (KTPH Website).
The KTPH design was developed from the winning entry selected from an international
consortium led by CPG Consultants Pte Ltd (CPG) from Singapore with many multi-
disciplinary team members (Appendix IV). CPG is the firm where this dissertation
author is currently working in. The author had no involvement in the KTPH project, but
facilitated the investigation of KTPH s design process, which may be difficult for
someone from outside the organization. Expressed consent was given by CPG as well as
personnel interviewed in this project for the information published in this document.
Situated in the northern Yishun town, the KTPH site is within walking distances to the
town amenities: Yishun Town Centre, Yishun MRT Station, Yishun Bus Interchange,
Yishun Town Park. It is adjacent to the existing Yishun Polyclinic, Yishun Pond, and a
planned site for a future community hospital (Figure 3.1). Across the Yishun Central
64
Road one finds the SAFRA club, which caters to all Singaporean citizens who have
served national service, situated in another park, the more hilly Yishun Park.
The KTPH design revolves around the concept of hospital in a garden, garden in a
hospital, as a response to the competition design brief which contained KTPH s vision:
hospital as a healing garden . The garden in a hospital (Figure 3.2) refers to a central
courtyard that opens on one side to the adjacent Yishun Pond, allowing visual and
physical connectivity between KTPH premise and the natural setting of Yishun Pond.
When viewed from the Yishun Pond s natural setting, KTPH becomes hospital in a
Figure 3.1 KTPH layout with reference to its site context. Source: CPG Consultants Pte Ltd
65
Figure 3.2 Garden in a Hospital: Courtyard view of Khoo Teck Puat Hospital with naturalistic,
lush greenery. Source: CPG Consultants Pte Ltd
66
Figure 3.3 Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond
Source: CPG Consultants Pte Ltd
YISHUN TOWN
CENTRE, TOWN
Physical
PARK, MRT
STATION, BUS integration of
INTERCHANGE green and View towards
social Yishun Pond and
environments Yishun Park to
engage nature
‘Garden in a
Hospital’ as
Community Space SAFRA/
YISHUN
PARK
Public and
shuttle arrival/ HDB
drop-off ESTATES
67
KTPH s landscaped environment not only provides the setting of healing gardens for
the well-beings of its patients and staff, it also lends itself to the Yishun community,
enhancing the opportunities for social and community interaction through the spatial
and compared to the visioning and objective setting in the integrated design approach
presented in chapter 2.
In the integrated design process, it is essential that the project establish clear vision to
align team members mindsets, attitude as discussed in Section . . and 2.3.3) and
commitment to align with the common purpose and shared values. This section
examines the rigour and commitment by KTPH in its visioning and bar-raising objective-
setting exercises; and how these have served as the navigation beacons to guide the
Focused group discussions were conducted with the KTPH project team members who
were involved in the project, either individually or in groups, over one or more sessions.
The discussions were made with reference to the IDP model (see Appendix IV on
discussion guide), and the project document made available to this dissertation author.
The use of the reference to IDP model is to ensure that the definition and mutual
in this dissertation. The objective of the discussions and reference to the project
document is to identify similarities and deviations between KTPH s design and work
processes in contrast to the IDP model. The project team members involved in the
68
Table 3.1 Key project team members involved in focus group discussions
(See also Appendix II)
Back in 2004, when the decision to build the KTPH was made, the vision was first set by
with patients unambiguously at the centre of the focus, with technology fully
exploited for the benefit and convenience of patients…. It will be a hospital which
is well linked… and to which the patients can be transferred seamlessly… It will
be a hassle-free hospital.
management and staff, led by the visionary and determined CEO Liak Teng Lit, who
had a tremendous impact in shaping the planning and operations of KTPH as well as
the organizational culture (Wu, 2011, p. 106). Under his leadership, and through working
committee (HPC), comprising eight key members representing the hospital management,
19KTPH was taken over by the management and staff from the Alexandra Hospital, while the
original Alexandra Hospital premise was transferred to JurongHealth in 2010. See History of
Alexandra Hospital. Available at <http://www.alexhosp.com.sg/index.php/about_us/our_history>.
69
a representative from Ministry of Health, as well as sixteen staff-in-attendance (HPC
Minutes of meeting dated 13.01. 2010), had developed a set of shared values as presented
in Table 3.2.
The above findings validated the emphasis in the integrated design approach to have
clear project vision from the start. In the case of KTPH, the CEO appeared to have played
stages, aligning the values and mindsets of the HPC and staff members.
S/No. Name
CEO Liak s personal philosophy viewing sustainability as an integral way of life,
1. and his vision in promoting sustainability as a lifestyle to his staff and the
community Liak, , p. .
2. CEO Liak s belief that in a food resource-constrained world… his hospital needed to
do their part through urban agriculture Ibid, p. . “s an outcome, KTPH
management teamed up with retired farmers in the community to volunteer and take
ownership of the roof top farm (Ibid, p. 107; Section 3.5.1)
3. Managers keep abreast with latest trends in healthcare and management issues (Ibid,
p. 106-107).
4. Patient-centric focus had become a shared vision among KTPH management and staff
(Ibid, p. 107). This was carried out through a series of pilot projects even while
operating at the Alexandra Hospital premise (DSC Case Study, 2009) . The initiatives
include shorter waiting time, access to better information, and savings on medical
bills. Ibid., p. The management tools and philosophies adopted include the
Toyota Production System TPS and Six Sigma to help improve the hospital s
workflow and efficiency Ibid., p. . “H also learned from leading organizations in
various industries including hospitality, airlines, finance, and manufacturing Ibid.,
p. 6).
5. Emphasis of energy efficiency and the use of natural ventilation to reduce energy
consumption (Wu, 2011, p. 109).
6. Enthusiastic staff e.g. Rosalin Tan that believes in increasing the indigenous wild life
biodiversity by introducing native species of plants in the hospital s landscaping.
(Ibid, p. 109)
7. “ believe in hospital as a healing environment in accordance with Erik “smussen s
seven principles: unity of form and function, polarity, metamorphosis, harmony, with
nature and site, living wall, color luminosity and color perspective and dynamic
equilibrium of spatial experience (Ibid, p. 110-111).
8. Ulrich s theory of supportive design (Ibid, p. 111), which is the domain of the
evidence-based design, presented in Section 1.6.2.
70
3.3.2 Setting the Objectives
Visions need to be translated into specific project objectives for targeted actions. In an
interview with Dr Lee Siew Eang 20 , who assisted KTPH in developing the project
objectives, he stated that the total building performance (TBP) approach was adopted to
develop the project objectives. The TBP approach was developed by Public Works
Canada between 1981 and 1985, and promoted by Hartkopf and Loftness as a framework
to measure building performance (Hartkopf and Loftness, 1999; Harkopf et al, 1986). It
focuses on integrating six key qualities of a building, namely spatial quality, thermal
comfort, acoustic quality, indoor air quality, visual quality, and building Integrity, with
reference to not only economic and building performance, but human physiological,
sociological, and psychological needs (Ng, 2005; Table 3.3). It is interesting that in TBP
approach, considerations which contribute to social sustainability are given under the
Spatial quality criteria, with qualitative attributes such as beauty , calm , excitement ,
view , etc. Set up in 2000, the Centre for Total Building Performance (CTBP), a joint
research centre by NUS and the Building and Construction Authority (BCA), adapted
the TBP approach21 to the Singapore context, with an aim to develop it into a design
performance-based, said Dr Lee in the same interview, and after the KTPH TBP matrix
had been developed, the Green Mark Platinum requirements were then slotted into the
20Interview session was held in January 2012. Dr Lee Siew Eang is Director, Centre for Total
Building Performance (CTBP). CTBP is a Joint BCA-NUS Centre for Tropical Building Research,
School of Design and Environment. Dr Lee is also an Associate Professor in Department of
Building, School of Design and Environment, National University of Singapore, with research
interest in building performance and acoustics.
21 Other projects in Singapore developed under the TBP approach include The Urban
Redevelopment Authority Centre of Singapore and the National Library Building (NLB) of
Singapore.
71
Table 3.3 Organizing performance criteria for evaluating the integration of systems (Hartkoft
and Loftness, 1999)
Specific
Economical
Performance Physiological Needs Psychological Needs Sociological Needs
Needs
Criteria
Ergonomic Comfort,
Habitability, calm, Wayfinding, Space
1 Spataial handicapped access,
excitement, view functional adjacencies Conservation
functional servicing
No numbness,
Healthy plants, sense
frostbite; no Flexibility to dress Energy
2 Thermal of warmth, individual
drowsiness, heat with the custom Conservation
control
stroke
Air purity; no lung Healthy plants, not No irritation from
Energy
3 Air Quality problems, no rashes, closed in, stuffy; no neighbours, smoke,
Conservation
cancer synthetics smell
No hearing damage, Quiet, soothing;
Privacy,
4 Acoustical music enjoyment, activity excitement
communication
speech clarity alive
No glare, good task Orientation,
Status of widnow,
illumination, cheerfulness, calm, Energy
5 Visual daylit office, sens of
wayfinding, no intimate, spacious, Conservation
territory
fatigue alive
Fire safety; structural Status, appearance,
Material/
6 Building strength and stability; Durability, sense of quality of
Labour
Integrity weather tightness, no stability, image construction,
Conservation
outgassing craftsmanship
Psychological
Physical Comfort Privacy, Material,
General Comfort
Health Security, Time,
Performance Mental Health
Safety Community, Energy,
Criteria Psychological Safety
Functional Images/Status Investment
Esthetics
By basing on the TBP approach, the KTPH HPC organized the visions into a set of thirty-
one objectives, grouped under nine categories (AH tender brief for design competition,
2005). This became the design requirements for the design competition. In order to make
a comparison between the TBP approach and the triple bottom line approach, these
objectives are mapped against the three sustainability dimensions of economic, social
and environmental/ecological, as shown in Table 3.4. While the design competition brief
was not explicit, the mapping revealed that all three sustainability dimensions of
72
At this stage, the alignment of values was confined to mainly the medical professionals,
with the assistance of Dr Lee and his team. The value alignment with the building
professionals has not yet been carried, because they are yet to be appointed. As a public
be procured through public tender. In an interview with Donald Wai, a key member of
the KTPH HPT, he said that it was decided very early on that an integrated design team
was needed for the KTPH project. This decision was in part informed by their previous
to another site in Jurong, and in part to meet the very tight project schedule to complete
KTPH. The requirements for the formation of an integrated design team and the
provision of the integrated design proposal were hence specified in the design
competition. A 2-stage design competition was held, based on the quality-fee method
(QFM; BCA22), in which shortlisted design consortium after Stage 1 proceed to submit
design and fee proposals in Stage 2. In the Stage 2 award evaluation, both the quality of
the design proposal and the total consultancy fee were taken into account, based on a
After the conclusion of the design completion, KTPH selected the winning design
submitted by the CPG-led consortium, and appointment the design consortium in May
2006. A visioning session was soon organized, to align the shared visions and to set the
objectives for the whole project team. The KTPH visioning and objective setting process
thus validated the IDP s emphasis on aligning values and mindset. At this stage, the
KTPH visioning and objective setting process as advocated in the IDP had been carried
The formation and organization of the multi-disciplinary building consultant team, and
its working relationship with the KTPH HPC and user group is presented in the next
section.
73
Table 3.4 Framing the sustainability focuses in KTPH s brief for design competition (AH,
2005), with sustainability attributes added by author.
a. Patients shall be at the centre of the focus, with technology fully exploited for
the benefit and convenience of the patients.
b. It will be well-linked, and patient transfer will be seamless.
2. Adopt a Tricycle Model : The three thrusts of patient care, teaching &
sharing, and learning & research will mutually support one another.
3. A hospital for the future:
a. It is to be visually pleasing that sustains with time.
b. Ensures ease and low cost of maintainability.
4. Design scalability:
a. Designed for flexibility and adaptability.
b. ”reathability in master planning.
c. Modular design for ease of conversion.
d. Ability for lock-down of the hospital by zone during emergencies.
5. Patient centric:
a. Hassle-free processes designed for patients convenience.
b. Engaging patients and their families as partners.
c. Safety of patients is of paramount importance.
d. Intuitive, ease of moment for patients and visitors.
e. Minimal movement required for patients.
f. Clustering of services and facilities.
6. Technology as an Enabler: Better, faster, cheaper and safer healthcare
through digitisation, wireless technology, automation and robotics.
7. Energy Efficient:
a. 50% More energy efficient than existing hospitals.
b. Designed to with the tropical climate in mind.
c. Harness natural ventilation.
d. Allow for ample overhangs.
e. Designed for high ceilings.
f. Make use of solar and wind power.
g. To achieve Green Mark Platinum Award.
8. High Touch:
a. To have a warm, cuddling feel.
b. Environment to be calming and cheerful.
c. Sensitive to the different age group of patient population, catering both to
the vibrant young and the mature aged.
9. Healing Environment:
a. Hospital within a garden, garden within a hospital.
b. Environment to have tranquil, restful, and healing qualities.
c. Users are in touch with the sight, scent and sound of nature.
d. Surrounding patients with nature, e.g. through roof garden, hanging gardens
at verandahs.
e. Replacement ratio of 0.7 or more for greenery.
74
3.4 KTPH Team Formation and Organization
Based on the individual and focused group discussions conducted with the project team
members, the organization chart of the original KTPH team organization was reflected in
a hierarchical manner similar to Figure 2.5. This is due to the fact that in the building
industry that is the commonly accepted way organizational charts are drawn. When
2.6), all project team members interviewed agreed that Figure 2.6 indeed better reflects
the KTPH team organization. Based on the findings of the focused group discussions, a
KTPH integrated design team organization chart (Figure 3.5) is prepared to reflect the
manner in which KTPH project team was organized. In Figure 3.5, building professionals
are shown in green, and communication among them was facilitated by the CPG
architects. The medical professionals are shown in blue, and communication among
them was facilitated by the HPT. The Core Project Team (CPT) comprises Architect,
prime consultant team, KTPH HPT, project manager and often includes landscape
Figure 3.5 KTPH s integrated design team organization. By author, adapted from IDP Roadmap (2007).
23Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
75
Through the focused group discussions, it was revealed that while the project team
members intended to undertake design and the project in an integrated manner, they
were not aware and hence did not make use of any specific integrated design process
methodologies, such as those identified in Chapter 2.0. They were therefore very much
group dynamics that was evolving and developing through working on the KTPH
project. The group dynamics began to mature as the project develops, and was stabilize
after about six months since the formal appointment of the consultants in May 2006. As
the appointment of the consultants did not make IDP a prescribed requirement, the fee
structure is similar to the traditional design approach. In other words, the fee structure
did not anticipate the rigour of the IDP. Hence throughout the project, the project team
had to adapt to the IDP practice while operating under the financial pressure of a
The roles of the key members of the KTPH Integrated design team are discussed in 3.4.1
to 3.4.6.
One key difference between the KTPH integrated design team and Roadmap (2007) is
the lack of a formerly appointed champion or facilitator. While KTPH s CEO Mr Liak
Teng Lit was the defacto leader in championing sustainability issues as outlined in
Section 3.3.2, and availed himself in many of the workshops or small group meetings, he
could not be considered as an IDP champion. Understandably so, as first, a specific IDP
methodology was not consciously adopted; second, it was never a practice in Singapore
for such a role. The prevailing practice was for the architect to act as the lead consultant
to co-ordinate the efforts of the consultant team, or for the large and complex project, for
a project manager to be appointed to act on behalf of the client to oversee the project
matters. For KTPH, the project team members recounted that the integrated design
24Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
76
efforts do require facilitation, and through group consent that the facilitation
responsibilities were taken up and shared among the CPG architectural team, the KTPH
HPT, and the PM Link project management team. The architectural team members
focused on facilitation among the building professionals. The HPT focused on liasison
and coordination with the many user work groups and hospital departments. The
scheduling which is typical of what project managers do in Singapore. The roles of the
project team members that played key roles to the integrated design process are
presented below.25
3.4.2 The role of the Architect + IDP Facilitator for Building Design
For KTPH, a 10-member architectural team was deployed by CPG, including the project
director Mr Lee Soo Khoong, architects Lim Lip Chuan, Jerry Ong and Pauline Tan who
were interviewed in focused group discussions for this dissertation. They worked in
collaboration with healthcare architectural consultant RMJM Hillier, and are supported
support staffs. Hence, team-based design was an important attribute in the architectural
design process.26
As the lead consultant, the CPG architectural team leads the building professionals in
engaging the HPT and the user representatives, as well as the building authorities. They
put in lot of efforts to facilitate inputs and requirements from different parties to be
tabled early, so as to seek opportunity for more holistic solutions. They also have to be
open to new ideas, possess good listening skills, and the willingness to learn and
staff, as well as the needs and requirements of patients, families and public visitors.
77
Some of the difficulties encountered by CPG architects were the initial communication
problems with non-building professionals, e.g. even when both parties were reading the
same drawings, the interpretation and spatial understanding of clinicians and the
1. Extra time spent and additional efforts were hence needed in order to ensure that
ideas that they had preferred may be constraint by other requirements, and
involving co-learning were hence necessary. On the other hand, the intense
meetings had also built trust and understanding among building and medical
professionals.
3.4.3 The role of the Hospital Planning Team + IDP Facilitator for User
Groups
The 9-member hospital planning team (HPT)27 is the bridge that straddles between the
building design/project team and the hospital management represented by the Hospital
Planning Committee (HPC) and user committees. Led by the Chief Operating Officer
Chew Kwee Tiang 28 and deputized by Donald Wai, the HPT comprises clinicians,
managers and administrators (AH org chart dated 09.01.2009) who would liaise with
27 The HPT initially comprises Director, Hospital Planning Chew K. T., Deputy Director Donald
Wai who oversee day-to-day hospital planning issues with focus on contract administration and
facilities management, Koh Kim Luan, Sim Siew Ngoh and Esther Yap in the early stages. Cynthia
Ong, Lye Siew Lin, Poh Puay Yong joined the project and HPT in later stages. All were involved
in specific departments based on their background. They help to bridge between the users and
consultants, were involved in NSC tenders (ID, fitment, loose furniture tenders etc) and site
coordination (Based on interview with CPG Architect Jerry Ong in Jan 2012 and AH org chart
dated 09.01.2009).
28 The role was performed by Grace Chiang up to the masterplanning stage, but later taken over
78
The HPT organized a few types of meetings/workshops:
and management issues were raised for decision making. Annotated agenda for
each HPC meeting was submitted to the participants, and key decisions were
made timely to facilitate the design process. In addition, the latest trends in
medical process, procedures and (operation) were also presented in the meetings,
and hard decisions were made decisively to incorporate some proposals into the
2. A one-week workshop was conducted once every month (User group design
architect, the prime consultant team (civil & structural engineer, mechanical
signage consultant were frequently present, particularly when their inputs were
required.
The Civil & Structural Engineers, Mechanical Engineers, Electrical Engineers were from
the same company as the architect, i.e. CPG Consultants Pte Ltd. This helped to reduce
potential hurdles that may impede close collaboration between the disciplines that are
from different companies, e.g. sharing of information. By being co-located in the same
building, the physical proximity between the various disciplines had also facilitated the
face-to-face interaction and design collaboration. Despite that, the focused group
discussions had also revealed that the habits developed from the entrenched linear and
fragmentary industry practices was hurdles that require persistent efforts to overcome.
79
3.4.5 The role of the Green Consultant
The CPG team was supported by its in-house green studio, CPGreen, headed by Dr
Nirmal Krishnani29 at that time during the early research stage of the design competition.
The Green Consultant role was taken up by Total Building Performance Team (TBPT)
during the design competition. They are familiar with the then new Green Mark
requirements, and provided the design team with support on climate analysis, energy
modeling, life cycle cost estimation, computational fluid dynamic (CFD) simulation, and
wind tunnel test. By utilizing these tools, TBPT worked with CPG architect and engineer
1. The bioclimatic responds of the building envelope, reducing the cooling load,
recovery system, CO2 sensor, and other energy-efficient systems e.g. lighting,
transportation, etc.
Dr Lee Siew Eang who headed the TBPT recounted30 that initially, the engineers were not
comfortable providing design information to the TBPT. The trust gradually built up after
a few months, with TBPT making it a point to always return to the engineers to discuss
their findings, before they would jointly present the outcomes or proposals to the
HPT/user groups.
Prior and throughout the project, some twenty-plus user groups were formed e.g.
management groups (Table 3.5). Generally, these user groups would first conduct their
own work flow studies, benchmarking practices from the best-in-class, propose system
29 Interview session with Dr Nirmal Krishnani held in December 2011. Dr Nirmal is currently
Senior Lecturer at National University of Singapore, as well as Chief Editor of Future Arc journal.
30 Interview session held in January 2012.
80
improvements, and translate these into design and spatial requirements for discussion
with the architect and the prime consultant team. These working sessions are facilitated
Table 3.5 AH/KTPH user work groups / departments (AH org chart dated 09.01.2009)
The main contract was procured using the conventional design-bid-build method, and
hence the main contractor M/s Hyundai Engineering & Construction Co Ltd were on
board only after the award of the main tender, and was not able to participate in the
integrated design process. The project team experienced some coordination issues
during construction stage, which affirms the view that there is a disconnect between
design and construction professionals (7group and Reed, 2009, p. 10; Section 2.1).
through document review and focused group discussion, it was found that the KTPH
project had by and large put in place the following essential elements of the integrated
design process:
81
1. Formation of multi-disciplinary, integrated project team that comprises not only
2. Robust visioning and objective setting processes were carried out, through the
With the integrated design team, the visions and objectives in place, it remains to be seen
how the integrated design process and iterations were played out. This is examined in
82
This requires rethinking principles and
accompany change.
David Orr
Dan Heinfeld
83
Chapter 4.0 KTPH s Integrated Design Process
This chapter examines KTPH s design process. The objective is to compare and contrast
the integrated design process in theory and in practice. Three aspects are focused on:
role that the different professionals or experts played, and the contributions they
made.
The methodology includes, first, by mapping out the KTPH s design process, focusing
the IDP theoretical model, followed by a discussion. Next, examination of the iteration
processes are conducted through the various stages: design competition stage, schematic
design stage and design development stage. During the examination, the tools and
focus is drawn on the two salient features of KTPH: the biophilic site layout and massing
design that was developed in the early design stages, and the bioclimatic and naturally
ventilated subsidized ward design that was developed in the later design stages. The
document available, as well as through focus group discussions with the key project
Based on the focused group discussions, the integrated design process of KTPH is
mapped out in Figure 4.1. For ease of comparison, the IDP theoretical model in Figure
research/analysis activities are quite similar between the KTPH process and the IDP
theoretical model, but the two starts to deviate during the schematic design stage. The
84
main activities that took place during the various stages in the process map are
W2 S1 VE1 VE2 S2
W1
DC MP SD DD1 DD2 CD
Figure 4.1 Integrated design process in KTPH. Adapted from WSIP (2007).
W1 W2 W3 W4 W5 W6 W7
R1 R2 R3 R4
Figure 4.2 The Theoretical model of integrative design process. Adapted from WSIP (2007).
The initial research/analysis stage R1 in the theoretical IDP model (Figure 4.2) is
undertaken as the design competition stage DC in the KTPH (Figure 4.1). The design
proposal put forward by the design team (See Figure 4.3) is indeed an attempt to address
(Lawson, 2005). As the design competition was conducted in two stages, feedback given
to the design team after the first presentations was given due considerations and an
improved design was put forth in the final submission. At this stage, the design concept
85
responded to the competition design brief was established. The design integrated inputs
and basic considerations from various consultants, including CPG s file archive
2. Interior design
3. Wayfinding
9. Landscape design
Figure 4.3 Integrated design team organization at the design competition stage. Adapted from
IDP Roadmap (2007).
The design led to the successful award of the design competition and the formal
appointment of the consultant team. KTPH HPT s Wai recalled that one of the reasons
was the support of the design concept by objective data and analysis. For example,
and computer simulation that by opening the courtyard towards the Yishun Pond, wind
86
4.1.2 W1: Visioning Workshop
In Section 3.2.2, it was presented that a visioning workshop was conducted soon after the
1-day visioning workshop, the KTPH key representatives and the building professionals
participated in a project chartering process, in which the project visions and objectives
were thought through, debated, and chartered with all participants committing to it by
signing off the charter. “rchitect Ong recalled, It was emphasized to us that we are
At this point, the project team had expanded to include both building professionals and
healthcare professionals in the Core Project Team, with other supporting building and
conducted over four days, in which the programmatic requirements, the site planning,
the massing iterations were conducted through the use of sketches, simplified digital
massing studies, powerpoint slide presentations and verbal discussions. Drastic changes
After the masterplanning workshop, the building professionals proceeded with the
design revision and iteration process. At this stage, preliminary design studies were
conducted to validate that the objectives set out in the visioning workshop were
achievable. This stage may be considered as part of the schematic design (R2) of the
theoretical IDP model. The stage was completed with the signing off of the revised
87
masterplan (S1), which took place after a presentation to HPC was made and
endorsement by HPC was obtained. The signing off was more for the purpose of
recognizing work done and billing for the building professionals. In terms of design
activities, the transition from masterplan to schematic design was an on-going process,
fuzzy process.33
Issues that required a more detailed level of resolution was brought into the schematic
design (SD) stage. During this stage, the block massing, spatial organization of
departments in relation to each other, was decided. More user groups (See Section 3.4.6)
were brought in to interact with the Core Project Team (CPT; See Section 3.4). The CPT
was usually represented by the HPT, architect, mechanical engineer, electrical engineer,
with other professionals e.g. landscape and interior designers joining in as and when
required. The user groups were coordinated and facilitated by the HPT and project
manager team. The user group meetings were typically a process of co-learning, where
the users would take the building professional through their specific operational
requirements, while the building professionals would explore design options while
construction. As recounted by Architect Ong34, during this process, KTPH s CEO Liak
Teng Lit would often attends the user group meetings for key decisions to be made,
“ VE workshop VE was conducted at the end of the schematic design (SD) stage. An
external facilitator was brought in by KTPH to facilitate the VE process. The different
33 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
34 Interview session held in Jan 2012.
35 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
88
options of the main building elements, e.g. link bridges, M&E design strategies, medical
service strategies, etc were presented, their pros and cons discussed, and at the end of
the VE workshop, decisions were made regarding which major design options were to
be selected.36
During the design development (DD) stage, there were two sub-stages. In DD1, internal
layouts of the individual departments were developed with the users. It was followed by
DD2, where the detailed room requirements were agreed, e.g. provision and locations of
equipment and services. Throughout the DD, the building professionals were essentially
developing the design into more specific systems and components, supported with
design tools such as calculations, simulations and metrics. Throughout this process, the
HPT and project manager would conduct interim reviews to check that the design
objectives were being met. In fact, as the design was being developed, many of the
engineer Toh Yong Hwa37, one of the KTPH s objectives was 50% more energy efficient
than existing hospitals . This was initially based on an assumption that 70% of the floor
the design developed, it was realized that even after optimization, 54% of the floor areas
energy saving target was agreed to be revised to 35%.38 The design development was
signed off S in Figure . for the preparation of the tender bid documentation. “gain,
this was more meaningful for the recognition of work done and billing; the actual design
36 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
37 Interview session held in January 2012.
38 This was nonetheless a higher target than the minimum energy saving criteria of 30% for Green
Mark Platinum.
39 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
89
4.1.8 VE2: Value Engineering Workshop
A second VE workshop (VE2) was conducted in between DD1 and DD2, primarily to
decide on the façade screen design options generated. Again, an external facilitator was
appointed to facilitate the VE process. The different façade screening options were
presented and evaluated, and at the end of the VE workshop, decision regarding which
From the above process map, it is observed that workshops were held frequently
throughout the project duration. CPG Architect Lim41 commented that hospital planner
RMJM-Hillier were familiar with the group design technique of design charrettes 42
(Todd, 2009), which they frequently employed in their projects. For KTPH, workshops
foreign consultant, as the physical distance of their home office in the United States
Singapore. Instead, a focused one-week workshop where all key stakeholders are present
to be held on a monthly basis was more effective, and it had become an established
practice with the Singapore-based project team as well, even after RMJM-Hillier had
completed their main scope of works by DD1 stage and stopped participating on a
regular basis. KTPH s Wai recounted that in between the main workshops involving key
stakeholders, many user group meetings to resolve design issues were needed. As many
of the users are clinicians and managers who had to perform duties during official hours,
it was necessary to conduct user group meetings with building professionals through
intensive mini-workshops, very often between 5pm and 10pm after working hours. Such
intense sessions were prevalent in the masterplanning and schematic design stages, but
40 Ibid.
41 Interview session held in January 2012.
42 Todd (2009) defined design charrettes in Whole ”uilding Design Guide website as a charrette
is defined as an intensive workshop in which various stakeholders and experts are brought
together to address a particular design issue, from a single building to an entire campus,
installation, or park.
90
the intensity began to reduce in design development stage, as the design was
progressively resolved.43
Not shown in the process map are the monthly HPC meetings, where the CEO, COO,
project. The interim solutions agreed between the user groups and the building
professionals in the workshops were presented in HPC meetings for endorsement. Issues
that could not be resolved at the workshops (e.g. inter-departmental conflicts, etc) or
are identified in annotated agenda to be iterated in the HPC meetings for decision. On
the other hand, issues surfaced during the HPC meetings were also assigned to specific
user group working sessions for detailed study and/or resolution. While VE exercises
were not conducted as an on-going process as advocated in the theoretical model of IDP,
While KTPH s design process map somewhat deviated from the theoretical model of the
IDP, it has so far validated such recommendations (WSIP, 2007, see Table 2.4) as:
2. Assemble the right team (WSIP, 2007), in the case of KTPH, this includes both
4. Align team around basic aspirations, a core purpose (a hassle-free hospital), and
43Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
91
5. Sustainable design brief: The core values were translated into a set of actionable
The next section of this dissertation is to examine some examples of the iterative process
and outcomes. In the examination, the tools and techniques employed to support the
In Section 2.3.3.4, the model of the iterative process (Figure 2.9) proposed in Strategies
for integrative building design by van der Aa, Heiselberg and Perino (2011) was
discussed. This model, hereby known as the iterative process model (IPM) is used in this
part of the dissertation to examine selected aspects of the iterative process in the KTPH
Research/Analysis Workshops/
Decisions
SD
DD1
DD2
Figure 4.4 KTPH iterative process basing on the model in Strategies for integrative building
design (van der Aa, Heiselberg and Perino, 2011).
Text in red added for referencing with KTPH process map (Figure 4.1).
92
4.2.1 Schematic Design (SD) Stage
SD VE1
Schematic Design
(Concept Design)
Figure 4.5 Iterative process model during the schematic design phase. Adapted from van der
Aa, Heiselberg and Perino (2011). Red annotation added for referencing with KTPH process
map (Figure 4.1).
During the schematic design stage (known as concept design phase in IPM), broad
circulation strategy, green design strategy, site response, etc. A diagramme represented
this part of the iterative process is shown in Figure 4.5 (Ibid., p. 9). In the case of KTPH,
this took place in the masterplan and schematic design stages MP and SD in Figure
Based on Architect Lim s reflection44, he learnt from the masterplan workshop that the
main reasons for KTPH s selection of the CPG-Hillier scheme as winning entry for
1. The scheme revolving around a garden as the heart of the scheme. This opens
that the KTPH management team had established since year 2000 in their
previous premise, “lexandra Hospital. The KTPH HPC s firm belief and
93
environment to harness its therapeutic properties, not only for patients, but also
for patients families, visitors, and hospital staff had since the masterplanning
workshop became ingrained into the building professionals mindset. This belief
is supported by the biophilia hypothesis (Wilson, 1984; Kellert et al, 1993) and
actionable performance criteria, KTPH s CEO Liak specifically set such challenge
for the design team: Walking distance for patient from arrival point to the
accident and emergency department shall be no more than 20m; to the clinics, no
3. The layout demonstrated that good potentials for natural ventilation, which
The said shared values were taken up by the integrated design team. In response, design
and performance-simulated studies were focused on refining and improving the site
The design tools utilized during this stage to support the iterative process includes
syntax45 (Figure 4.5), traffic simulation performed by CPG Transport, ETTV calculation
45Space Syntax claimed to developed evidence-based methods for analysing spatial layout,
observing patterns of space use within the hospital environment and designing ward layouts and
94
Table 4.1 Integrated Design Activities
The landscape drawings by Peridian Asia (Figure 4.6 to 4.10) demonstrated the design
outcome at this stage, where biophilic design took centre-stage; one in which building
and constructed landscape foster a positive connection between people and nature in
places of cultural and ecological significance and security Guenther and Vittori, 2008,
p. 88). The biophilic approach set the stage for further and deeper collaboration between
the KTPH hospital planning team and building professionals. For example:
hospital circulation which optimise space use, wayfinding and interaction. These techniques work
by measuring the properties of spatial layouts that users perceive: lines of sight along streets and
corridors, visual fields from reception areas and nurse stations and degrees of openness and
privacy. Healthcare at Space Syntax website . ”ased on Hillier s space syntax theory Hillier,
1999), it is being promoted as a evidence-based approach (Sailer et al, 2010).
95
1. To engage in place-making , a term used by the KTPH hospital planning team in
looking out for opportunities to create landscaped corners, seating areas, terraces
(Figure 4.8 to 4.11), for patients, families, staff, and breakout spaces where
2. To enhance the thermal comfort of roof terraces (Figure 4.9 to 4.11), spot cooling
spaces into these landscaped roof terrace areas. Mechanical Engineer Toh said
Architect Ong added that to complete the integrated design, it was necessary for
the architect and landscape architect to consider the integration of the exhaust
with the façade and landscape design. “s a result, waste from one system
Figure 4.6 Landscape plan showing landscaped courtyard as the heart and lung of design.
Source: Peridian Asia; CPG file archive
96
Figure 4.7 Landscape schematic drawing. It
shows landscaped courtyard as the heart,
addressing main entrance as arrival/foyer,
opens to basement 1 for light and ventilation,
and surrounded by landscaped terraces. The
replacement rate for the greenery is 70%.
Source: CPG Consultants Pte Ltd
Figure 4.8 Sketch design for landscaped roof terrace as social space, while providing good
shading, insulation to interior spaces below, and integrated with spot cooling by recovering
cooled temperature from exhaust air. Source Peridian “sia CPG file archive
97
Figure 4.9 Landscaped oof terrace at Level 4 where patients, visitors, staff may enjoy moments
of solitude or share moments of comfort or grieve; it is also a source of visual relief from the
wards. Source: Peridian Asia; CPG file archive
98
4.2.2 The Design Development (DD1) Stage
DD1 VE2
Design Development
(System Design)
Figure 4.11 Iterative process model during the schematic design phase.
Adapted from van der Aa, Heiselberg and Perino (2011)
As the design process enters the design development stage (DD1; known as system
design phase in IPM; Figure 4.11), van der Aa, Heiselberg and Perino proposed that
integration of system design be carried out. For KTPH at this stage, block layout and
floor plans reflecting each department s operational work flow were progressively being
iterated and agreed. Specific architectural and technical solutions were proposed,
supported by design calculations and simulations. During this phase, the design team
The bioclimatic response of the KTPH site planning is shown in Figures 4.12 (sun path)
and 4.13 (prevalent wind directions). The orientation of the blocks, as constraint by the
site boundary and the primary objective of orientating the courtyard towards the Yishun
Pond, is less than ideal as the private wards tower (P) is directly exposed to east and
west sun, while the subsidized ward (S) and the specialist outpatient clinics blocks (SOC)
are exposed to east and west sun at an angle, and the project team noted that careful
envelope design was required to address that. On the other hand, as stated in Section
4.1.1, the site orientation does facilitate air movement from the prevalent wind directions
through the courtyard. One other consideration is to place the naturally ventilated
subsidized ward tower furthest away from the main road as it is most vulnerable to
99
Stereographic Diagram N
Location: SINGAPORE, SGP 345° 15°
330° 30°
10°
315° 45°
20°
30°
300° 60°
40°
1st Mar
SOC
15 14 13 12 1st Nov
255° 16 11 105°
1st Feb 10
18
17
P 9
8 1st Dec
1st Jan
19
240° 120°
225° 135°
NV Ward Outline
210° 150°
ds
rs) NORTH hrs
345° 50 km/ h 15°
Location: SINGAPORE, SGP (1.4°, 104.0°) 381+
ember
330° 30° 342
© Weather Tool
40 km/ h 304
266
315° 45°
228
30 km/ h 190
152
300° 60°
114
20 km/ h 76
<38
285° 75°
S
10 km/ h
WEST
SOC EAST
SOC
SOC
255° 105°
P
240° 120°
225° 135°
195° 165°
Overall Massing Outline SOUTH
100
In addition, the breeze across the open pond park land area would also be more
beneficial to the naturally ventilated wards than the air-conditioned private wards.
In the design, the project team had also taken into account the aspect ratio of the block
ventilation, shallow plans were adopted for the naturally ventilated subsidized ward
tower. The air-conditioned private ward tower and the specialist outpatient clinics block
were designed with deeper plans to reduce the envelope-to-space ratio, so as to conserve
energy by minimizing heat gain through thermal exchange of the envelope. A critical
review based on ”RE s environmental design guidelines (Rennie and Parand, 1998)
revealed that the naturally ventilated ward design have satisfied the environmental
design guidelines (Figure 4.15). For example, the room depth to height ratio of 2.5 or less
was achieved for natural ventilation. This does mean that the day light penetration of
room depth to height ratio of 2.0 was marginally sub-standard; hence the integrated
design again came into play. Architect Ong recounted that when light shelf was
daylight distribution. After that, to meet the lighting performance criteria of 550lux,
M&E engineer Toh Yong Hua designed artificial lighting linked to photo-sensors. The
artificial lighting will only be turned on when the photo-sensors detect that the daylight
Naturally Ventilated
Subsidized Wards
70m 30m
20m
75m
40m
40+3m
35m
75m
Figure 4.14 Aspect ratio of the various block. Source of base drawing: CPG Consultants Pte Ltd.
101
0.8m 0.7m
0.4m 0.6m
Light External
4.2m 2.7m Shelf shading
Wind wall
H = 3.3m
2H = 7.6m
H = 3.3m
2.5H = 8.25m
Figure 4.15 Critical review based on Environmental Design Guide for Naturally Ventilated and
Daylit Offices Rennie and Parand, . Source of base drawing CPG Consultants Pte Ltd.
level has fallen below 550lux. As a result, energy is consumed only when it is absolutely
necessary to meet the performance required. For air-conditioned areas, this also resulted
Toh added that for the air-conditioned single-room private wards, local control is
provided to the patients. For patients who prefer natural ventilation, the windows are
openable. When the windows are opened, the micro-switch at the window would
immediately deactivate the air-conditioning system, hence reducing chill water usage,
conserving both energy and water usages. The air-conditioning system design must
therefore incorporate control systems that dynamically monitor the demand. To match
demand with supply as closely as possible, variable flow chilled water system is used.
The demonstration of integrated design effort at this stage is most clearly seen in the
integrated envelope design solution to balance the considerations for view, day lighting
and thermal comfort by examining influencing factors holistically as shown in Table 4.2.
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Table 4.2 Integrated design considerations for façade, thermal comfort and energy usage
The role and activities played by the various team members are summarized in Table 4.3.
Each design iteration of the façade system (by architect; Figure 4.16 to 4.21) were
cost estimate (by quantity surveyor), and estimation of life-cycle electrical consumption
as an outcome to the resultant cooling load (by electrical engineer). These factors of
daylight, natural ventilation, shading coefficient, aesthetic, capital expenditure, and life-
ventilation strategy, view, rain protection, and aesthetics were performing as a system
103
Figure 4.16 Design study 1 for façade shading of the naturally ventilated ward tower.
Source of drawing: CPG Consultants Pte Ltd.
Figure 4.17 Design study 2 for façade shading of the naturally ventilated ward tower.
Source of drawing: CPG Consultants Pte Ltd.
104
Figure 4.18 Design study 3 for façade shading of the naturally ventilated ward tower. This
design was selected to maximize NV and lighting. Source of drawing: CPG Consultants Pte Ltd.
Figure 4.19 Design developed from Option 3: Fully height louvred façade and light shelf
maximizes natural ventilation and daylight. Source of drawing: CPG Consultants Pte Ltd.
105
Figure 4.20 Design developed from Option 3: Effect of rain needs to be considered in the tropics.
These diagrammes indicate integration of monsoon windows providing ventilation during rain,
even when the louvred windows are closed. Source of drawing: CPG Consultants Pte Ltd.
Figure 4.21 Interior of naturally ventilated ward: Façade system comprising louvred wall, light
shelves, and monsoon window. Natural ventilation is supplemented with individually
controlled fans. Source of image: CPG Consultants Pte Ltd.
106
4.2.3 The Component Design (DD2) Stage
DD2 S2
Figure 4.22 Iterative process model during the late design development (DD2) phase.
Adapted from van der Aa, Heiselberg and Perino (2011)
In the late design development stage (DD2; known as component design phase in IPM;
Figure 4.22), van der Aa, Heiselberg and Perino proposed that component design and
selection are carried out to develop and complete the system design.
For KTPH, examples of the integrated design activities at this phase are selected to
demonstrate system thinking and system efficiency, as summarized in Table 4.4, and
Table 4.4 Integrated system design and system efficiency within systems
Categories Description
Study of air movement leading to the integration of wind wall on
1. Interdependency of façade
the façade of the naturally ventilated subsidized ward tower. This
system, thermal comfort system,
is to refine the façade system proposed in DD1 stage (Section
daylight/lighting system
4.2.2). This is briefly presented in Section 4.2.3.1
To support the idea of enhancing the thermal comfort of roof
2. Interdependency of air-
terraces, to facilitate its use as outdoor social space (Section 4.2.1),
conditioned system and natural
detailed design of the spot cooling design was tested using CFD
ventilation system
simulation. This is briefly presented in 4.2.3.2
By discharging rainwater into Ponggol Pond, and utilizing
3. Interdependency of built Punggol Pond water for irrigation and outdoor washing to
environment and natural systems consume the use of portable water, reducing carbon footprint in
the process. This is briefly presented in 4.2.3.3
Finally, energy-efficient system and resource-efficient system
4. Resource efficiency within each
design is carried out for M&E engineering design. This is briefly
M&E system design
presented in 4.2.3.4
107
4.2.3.1 Wind Wall at the Naturally Ventilated Subsized Ward Tower
Architect Ong recounted that during this stage, for the naturally ventilated subsidized
ward tower, computational fluid dynamic (CFD) and wind tunnel studies were
conducted to study the air movement to ensure that it functions well. Through the study,
it was found that air speed from the southern prevalent wind was less than the desirable
0.6m/s most of the time47, and TBPT proposed the use of wind wall as a device to
increase wind pressure on the façade, hence inducing the wind into the interior. A
second round of CFD and wind tunnel study was conducted to ensure that the wind
Figure 4.23 Sampling points measured in wind tunnel study. Source: TBPT; CPG file archive
47Relative air speed of 0.6m/s was targeted to result in the thermal sensation of about 2°C drop in
temperature (Butcher, 2005).
108
Figure 4.24 A sample of the air velocity profile across a typical ward at 1.2m height @ open, 50%
open and closed conditions. Source: TBPT; CPG file archive.
Figure 4.25 A sample of the pressure coefficients chart across the façade of the subsidised ward
tower obtained as boundary conditions for the CFD study. Source: TBPT; CPG file archive
109
Figure 4.26 1:20 Wind tunnel model used for the study. Source: TBPT; CPG file archive
Figure 4.27 Subsidized ward tower façade showing solar screen to provide shade and wind
wall to induce air movement. Greenery is also integrated into the façade to enhance visual relief.
Source: CPG Consultants Pte Ltd
To enhance the thermal comfort of landscaped roof terraces (Section 4.2.1), spot cooling
was introduced by directing the cooled exhaust air from operating theatres into these
roof terrace spaces. Dilution, high-efficiency particulate air (HEPA) filter and UV
sterilization were techniques used to ensure infection control. Mechanical Engineer Toh
affectionately named the system New Air , and CFD (Figure 4.28 to Figure 4.32) and
110
evidence-based evaluation (Table 4.4) was performed at this stage to research the
outcome before its implementation. The adaptive re-use of waste from one system
Figure 4.28 Design drawing showing location of exhaust nozel integrated into the façade, and
the direction of throw to cool the landscaped roof terraces. Source: CPG Consultants Pte Ltd
Figure 4.29 CFD Simulation showing approximately 2°C reduction in temperature at the roof
terrace, delivering cooling sensation to users. Source: CPG Consultants Pte Ltd
111
Figure 4.30 CFD simulation showing the throw of exhaust nozzle, and the wind speed gradient.
A 2m/s wind speed is achieved at the end of the throw. Source: CPG Consultants Pte Ltd
50 m
40 m
30 m
10 m
5m
0m
57dBA
43dBA
37dBA
31dBA
27dBA
25dBA 23dBA
Figure 4.31 Noise level (dBA) at various distances (m) from the nozzle diffuser. The noise level
at landscaped roof terrace at 5m away from nozzle diffuser is 43dBA, which is equivalent to
outdoor ambient sound level. Source: CPG Consultants Pte Ltd
112
Figure 4.32 Selection of component: Oscillating nozzle diffusers tested to ISO 5135 1997 and ISO
3741 1999 on sound power level performance to allow for better throw distribution.
Source: CPG Consultants Pte Ltd
Table 4.5 Evidence-based evaluation for New “ir spot cooling at outdoor roof terrace . Source
CPG Consultants Pte Ltd
Consider-
Reference
ations
1. Guidelines for Design and Construction of Healthcare Facilities, AIA 2006
2. HVAC Design Manual or Hospitals and Clinics, ASHRAE 2003
3. HTM 2025
4. Guidelines for Environmental Infection Control in Health-Care Facilities, CDC Atlanta
Standards 2003
complied 5. Guideline for Preventing the Transmission of Tuberculosis in Health-Care Settings,
with CDC
6. Meeting JC“HO s Infection Control Requirements, JCI 2004
7. EPA Technical Brief on Biological Inactivation Efficiency In-Duct UVC Devices
8. CP13 Mechanical Ventilation and Air-conditioning in Buildings 1999
9. Guidelines for Good Indoor Air Quality in Office Premises, NEA 1996
1. Sufficient DiLUTION of Exhaust Air can be achieved through mixing with outdoor air.
Reduction of ambient temperature at 2 to 4 be achieved.
2. STERIL-AIRE UVC in-duct emitters for INFECTION CONTROL provide germicidal
irradiation with periodical monitoring of bacterial counts and fungal counts according
to NEA guidelines on Indoor Air Quality(IAQ) by accredited Laboratory. The Emitters
are Environmental Protection Agency(EPA) tested proven industrial-grade air
Measures sterilizing system.
implemen- 3. The application exceeds the CDC guidelines, HTM and other design codes for
ted treatment of OT exhaust air.
4. All OT exhaust fans are coupled with in-out Silencers for acoustic treatment
5. All UVC emitter performance are tracked by BMS for real-time monitoring(round the
clock) using radiometers linked to alarm and fault reporting
6. Due to UVC failure, the application can be suspended as and when required for
individual OT or multiple OT exhaust by diverting the nozzle diffusers to the sky
7. The complete application can also be suspended under pandemic outbreak situation.
113
4.2.3.3 Water Efficient Landscaping Irrigation System
The rainwater collected within the KTPH site is discharged into Yishun Pond, adjacent to
the site. The raw water (non-portable) from Yishun Pond is then used for landscape
irrigation and floor washing in KTPH, to reduce consumption on potable water48, hence
reducing carbon footprint. Essentially, the rainwater resource and irrigation needs of the
KTPH site were seen as part of the larger hydrological cycle. Newater, water recycled
from sewage was used as a backup water source for the irrigation system (See Figure
4.33 and 4.34). In the system, efficient drip irrigation system and rain sensors were
Precipitation
Building-Integrated
Natural Environment
(Biophillic Architecture)
Rainwater
treatment
Rainwater Runoff
Built /Discharge Evapo-transpiration
Environment
Reduced Carbon Rainwater
Footprint Reuse Pond
water source with
New water source as
backup
Figure 4.33 Conceptual diagramme of irrigation system and built environment as part of
natural systems. Source: CPG Consultants Pte Ltd
Treatment and pumping of portable water consumes energy. By utilizing and replenishing raw
48
114
Figure 4.34 Schematic of irrigation system, drawing water from Yishun.
Source: CPG Consultants Pte Ltd
Toh commented that for mechanical & electrical engineering (M&E) design, it would be
crucial at this stage to select the most efficient M&E equipment available in the market,
and checking with manufacturers that the equipment performs well as a system (See
2. Based on the ETTV target agreed by the project team, architects confirmed the
window opening size and glazing material selection based on the appropriate
etc.
At this stage, green rating tools such as Green Mark metric were used to validate and
fine-tune green design. The measures adopted in KTPH are shown in Appendix VII to X.
115
4.3 Discussion: KTPH s Integrated Design and Iterative Process
This chapter highlighted some examples of close collaboration between the medical
professionals and building professionals in the KTPH project. The design process in fact
continued to develop during the construction phase (See Appendix X), which is not the
focus in this dissertation. Through the examination of KTPH s integrated design and
iterative process, it showed that even without having the benefits of referring to
structured IDP methodologies, by using a IDP methodology that was developed in-
house and customized by the project team to suit KTPH s unique requirements, many of
the IDP elements and practice measures advocated had emerged and were practiced in
the KTPH design process. The evaluation matrices that summarize the comparison
between the IDP model and KTPH are shown in Table 4.5 and 4.6, with reference to the
Table 4.6 Comparison between WSIP Process Elements (2007) and KTPH Design Process
Practiced in
Stage Essential Elements in WSIP Process Stages (2007, p.8)
KTPH IDP
1. Team Fully engage Client in the design decision process. Yes
Formation
“ssemble the right team. Yes
116
Table 4.7 Mapping KTPH s integrated design process against the IDP model with reference to
Figure 4.1 and 4.2.
WSIP (2007)
KTPH IDP Stages Comment
Stages
Research in KTPH design competition was
DC in Figure . done in an integrated building design team,
R in Fig .
Design Competition but without involve-ment of users e.g.
clinicians
W in Fig . W in Figure . Visioning Workshop This validates the IDP model for visioning.
Masterplan is not an expressed stage in IDP
- W in Figure . Masterplan Workshop model. This can be considered as part of SD
in IDP model.
MP in Figure . Masterplan Workshop
R and W This validates the IDP model for
S in Figure 4.1: Workshop + Sign off
in Fig 4.2 research/workshop.
masterplan
While KTPH s iterative process is more
SD in Figure . Schematic Design
R and W prolonged, it is due to the complexity of the
VE in Figure . Value engineering
in Fig 4.2 hospital typology. This more or less validates
workshop 1
the IDP model for research/workshop.
Design process in practice is more fuzzy, and
do not progress in distinct stages as in theory
DD in Figure . Schematic Design
R and W (Lawson, 2005). DD1 in KTPH may indeed
VE in Figure . Value engineering
in Fig 4.2 be considered as an extended SD. This,
workshop 1
together with a second VE workshop
appears to validates the IDP model.
Iterative design process in KTPH continued
- DD into DD2. This reflects the complexity of a
hospital typology.
The decision workshop to confirm the
W5 S outcome of DD in both IDP model and
KTPH again validates the IDP model.
KTPH s integrated design process in fact
extended beyond DD, into the construction
W6 CD and Construction Stage
stage, exploring other opportunities (See
Appendix IX).
process map of IDP model (Figure 4.2) and KTPH process map (Figure 4.1).
team-based design techniques and methodologies has been presented. This is validated
by the experiences and reflections by the project team members who had participated in
the KTPH integrated design process. In reflection, however, there are also lessons to be
learnt. In the next concluding chapter, the KTPH built environment as an outcome of the
discussion on lessons learnt from the research so far, and further recommendations.
117
The true value of an integrated process is an
Bob Berkebile
118
Chapter 5.0 Conclusion
Following the last chapter, in which the KTPH iteration process was presented, this
chapter briefly evaluates the KTPH built environment as an outcome of the integrated
presentation of the lessons learnt from the research on the practice of integrated design
in KTPH, which provides the materials for a discussion. Following the discussion, a few
various post-occupancy studies (Table 5.1), and is presented in Section 5.1.1 to 5.1.4.
S/No. Description
Preliminary energy consumption study conducted by CPG Mechanical Engineer Toh
1.
Yong Hua.
Sng, P. L. (2011). In What Way Can Green Building Contribute to Human Wellness in
2.
the Singapore Context? M Arch. National University of Singapore.
Wu, Z. (2011). Evaluation of a Sustainable Hospital Design Based on Its Environmental
3.
and Social Outcomes. MSc. Cornell University.
KTPH was certified as a BCA Greenmark Platinum building (see Appendix XI) in 2010,
Singapore and tropical context (See Appendix VII to X). Its key building performance
viable strategy for both in-patients and nursing staff (See Appendix XIII).
2. BCA Green Mark requires that the actual building performance be submitted one
year after occupation, to confirm that the design measures are implemented. In
119
preparation for the submission, CPG Mechanical Engineer Toh found that actual
during the design, with an average savings of 46.6% between July 2010 and Sep
Category Description
Extensive landscaping contributes to reducing heat island effets.
Site Naturally ventilated subsidized ward benefits from breeze from Yishun Pond.
Extensive tree planting.
Extensive use of natural ventilation (36% of floor area).
Naturally ventilated external corridor reduces space cooling demands.
Energy-efficient conventional M&E system design, resulting in energy reduction of
Energy
36.4% compared to baseline reference model.
Shading device on the façade to reduce solar heat gain.
Courtyard extends to basement to provide natural ventilation and daylight.
Yishun Pond landscape and social amenities improved. Rainwater runoff from site is
discharge into Yishun Pond in compliance with sustainable drainage design.
Water
Raw water from Yishun Pond is used for irrigation and outdoor washing.
Water-efficient fittings are used.
Naturally ventilated subsized ward tower is designed with shallow plan to maximize
cross ventilation.
Acoustic comfort was designed to meet performance objectives of stress-reducing
environment.
Indoor
Indoor air is treated with UVC and anti-bacteria measures to meet infection control
Environmental
objectives.
Quality
Naturally ventilated corridor engages landscape courtyard.
Lightshelves to maximize daylight in the interior.
Shading device on the façade to reduce solar heat gain.
Wind wall to improve natural ventilation.
Solar thermal hot water system generating 21,000litres/day to fully meet hospital
Renewable
needs.
Energy
130kWp photovoltaic system
Self-sustaining ecological pond.
Achieve spot cooling for outdoor landscape roof terrace social spaces by making use
of HEPA-filtered exhaust air from operating theatres.
Dual refuse chutes for separation of recyclable waste.
Siphonic rainwater discharge system to reduce pipe size, hence reduce space wastage,
Innovation
as well as to reduce noise.
Automatic waste and soft linen collection systems.
Auto tube cleaning system was used to reduce consumption by approximately 20%.
Composting machine was used to process food waste into fertilizer for roof and food
gardens.
120
5.1.2 KTPH: Embracing Social Sustainability
Post occupancy survey by Wu found that its natural environment has been the most
well-liked feature (Wu, 2011; see also Appendix XIV). This has directly or indirectly
(Ibid.), enhancing wellbeing for patients, their friends and families, visitors, public, as
Sng also found that these wellness dimensions of World Health Organizations Quality
of Life WHOQOL are in fact missing from ”C“ Green Mark rating system Ibid., p.
75). In focusing on technical performance of the built environment, Green Mark aims to
address the issues of reduced consumption of energy and resources, but it does not
address social and ecological dimensions of sustainability. Such are perhaps not the
current purpose of Green Mark rating system; but it also indicates that the objectives-
from the Green Mark rating system, as has been demonstrated through the visioning and
objectives-setting efforts in the KTPH Project using the TBP framework (Section 3.3).
environment with Ponggol Pond and the Yishun natural and community contexts, the
design has opened up opportunities for community and environmental stewardship for
KTPH, as follows:
VI).
2. Integrating with Yishun Pond environmentally and socially (Appendix XI & XV).
(Appendix XV).
121
KTPH management team has demonstrated track records and commitment in their
(See Appendix XV). By embracing the same approach in the much higher-density 3.5Ha
KTPH site that is one-third the size of the 13.5 Ha AH site, and having operated for
slightly more than a year, the outcome is still being monitored. What is interesting here
is that the design and operation of KTPH appears to move in a direction towards
Summarizing from Section 5.1.1 to 5.1.3, ten sustainable attributes are identifiable in
KTPH, as summarized in Table 5.2. These attributes are mapped onto the Sustainable
Healthcare Architecture Model proposed in Section 2.3.5, as shown in Figure 5.1. This
diagramme put forth the case of KTPH as a positive example of sustainable healthcare
1 Green building reduces carbon footprint due to less non-renewable resources
consumed (Section 5.1.1; Appendix VII, VIII, IX, X, and XII)
2 Staff morale and productivity improves due to better physiological,
psychological and sociological well-beings (Section 5.1.2; Appendix XIV)
3 High-performance green building reduces expenditure on utilities, resulting
in life cycle savings (Section 5.1.1; Appendix VII, VIII, IX, X, and XII)
4 Patient well-being, faster recovery (Section 1.6.2; Appendix VI and XIV)
5 Hospital clinician/staff well-being (Section 1.6.2; Appendix VI and XIV)
6 Family/visitor/public well-being (Section 1.6.2; Appendix V and XIV)
7 Community participation through community stewardship programmes
(Section 5.1.2; Appendix XIV and XV)
8 Biophilic environment, creating symbiotic relationship between human and
nature (Section 1.6.3; Appendix VI)
9 Ecological integration between KTPH and Yunshun Pond (Section 1.6.3;
Appendix VI, XI and XV)
10 Fostering biodiversity through environmental stewardship (Section 1.6.3;
Appendix VI and XV)
Patient Well-being
natural and ecological systems
Environmental Sustainability
Hospital Staff Well-being
Family/Visitor Well-being
Community Participation
Biophilic Environment
Ecological Integration
Fostering Biodiversity
Social Sustainability Economic Sustainability
Evidence-Based Wellness Green Building
Community-Stewardship High-performance
Built environment that supports integrated Built environment as holistic,
healthcare and social systems bioclimatic system of systems
Figure 5.1 KTPH: Sustainable Attributes mapped onto the Sustainable Healthcare Architecture Model.
Keeler and ”urke have stated, Integrated building design is the practice of designing
sustainably . The evaluation in this section validates that the integration design
approach is highly relevant and practicable to the healthcare architecture, at least in the
Singapore context. This has been demonstrated in the KTPH case study as characterized
123
5.2 Lessons Learnt on the Practice of Integrated Design from the
KTPH Case Study
Based on the documentation study and interviews from the project team members, the
The KTPH case study demonstrated that a close collaboration between the medical
professionals and building professionals had developed in the project. The design
process from masterplan, through schematic design, design development phases and
extended into contruction phase may be thought about as a long, collective dialogue,
allowing the stated objectives at the start of the project to be played out against other
constraints that are not apparent in the initial brief. These includes building authorities
requirements, budget, specific operational requirements that are only becoming visible
as building designers present the proposed internal layout, etc. As Lawson proposes,
The eventual developed brief listed more than 440 specific requirements, categorized
under 15 categories, much more than the 31 objectives under 9 categories at objective
124
This highlights one of the key challenges in the design of healthcare architecture:
Very often, they are developed and defined as the possible solutions are being tossed
about (Lawson, 2005, p. 120). Hence, KTPH demonstrated that for large scale and
complex project, there is a need for close collaboration with stakeholders, experts from
different disciplines, and key decision makers in the iterative process, because problems
often only emerged after tentative solutions are proposed (See Appendix II on team-
Aside from the close collaboration between the medical and building professionals, the
project team members had highlighted in the focus group discussions that they
conventional behavior of linear, parallel processes. As a result, there are instances where
more straight forward design issues that building professionals could resolve among
themselves are less satisfactorily done, when far more complicated issues that require co-
learning between the healthcare and building professionals were resolve far more
based on past experience and cut back on coordination with each other as they succumb
to time pressure; especially after committing huge amount of time and resources in the
This behavior tendency had occasionally crept into dealings with the medical
professionals as well. KTPH s Wai said that one short coming of the project team
members becoming very familiar and friendly with the KTPH staff, especially towards
the later phases of the project, is the tendency for individual building professionals to
seek consent from end users to resolve localized problems quickly, without seeking the
consent of the HPT or other inter-related departments. In other words, the problems may
not have been resolved systematically or holistically. This reveals that linear-thinking,
125
5.2.3 Issues Related to Mindset Change
Gathering from the interviews, it suggests that the mindset change among team
members was also not consistent: Some are more prepared to embrace collaboration and
adopt an open-minded attitude; others less so. This may be heavily influenced by the
background and personality of individual team members, and the organizational culture
where they belong to. In addition, the visioning and objective setting were heavily
focused on the healthcare perspective. With the benefit of hindsight, some sharing or
environment, between nature and built environment, and between building systems
within the built environment, at the very early stage of the design process would have
been beneficial.
The Integrated design process guide or toolkits, some of which were briefly explored in
Section 2.3, were not available to the KTPH project team during the project. It is believed
that such toolkit would have provided a more systematic guide to better manage the
Computer aided design (CAD) was used as the predominant design and documentation
platform, supported by manual sketches, disparate software analysis tools and building
documentation process that has typically been troubling the building industry:
126
5.2.6 Issues Related to Contractor Appointed via Conventional
Approach
were not included in the practice of integrated design. Coming on board after the tender
award, they had certainly missed most of the design iteration processes, where insights
and purpose of the project were reiterated through group dynamics and narration.50 In
addition, in keeping with the prevalent practice in the Singapore construction industry, a
professionals. In reality, the contractors simply could not cope with the demand of
designing and managing construction at the same time, especially under the intense
pressure of a fast track building programme. As a result, a significant degree of the early
good design intention faced implementation hurdles. A case in point is the need to lower
part of the ceiling heights in the wards due to the need to accommodate the M&E
services in the ceiling space, affecting the amount of daylight entering the wards.51
Arising from the lessons learnt, further questions may be framed using Batshalom and
1. Who is the leader in integrated design? Specifically, without the leadership from
AH/KTPH CEO Liak Teng Lit, would the outcome for KTPH be the same? Can
roles?52
coordinate the design during design development stage. This is indeed being done in some of
Singapore and CPG s current projects.
52 Refer also to Section 2.3.1 and footnote 15.
127
2. In the process of carrying out this research, one major challenge was the
investigation of the iterative process. As much of the iterative process was done
4. How would most holistic process change, e.g. as proposed in “I“ s integrated
Figure 5.2 KTPH Integrated design process: questions framed with the IDP Mental Model
There are no immediate answers to these questions, but they serve as good starting
128
5.4 Recommendations
Through the insights gained from the research, the following recommendations are
1. To research into the construction and commissioning aspects of KTPH and their
1 Building performance in terms of energy and water saving benchmarked
against local and international data.
2 Measurement of clinician/staff morale and productivity improves due to
better physiological, psychological and sociological well-beings.
3 Measurement of patient well being and recovery time due to the social and
environmental (i.e. biophllic) attributes of KTPH.
4 Measurement of family and visitor well being due to the social and
environmental (i.e. biophllic) attributes of KTPH.
5 Effectiveness of community participation in KTPH s community stewardship
programmes due to the social and environmental attributes in KTPH
6 Enhancement of ecological outcome, e.g. improvements in biodiversity
aspects of the integrated design process, to better understand how design though
processes and decisions are arrived at in a group setting. It will contribute to the
knowledge and hence practice of integrated design, and perhaps even spawn a
129
new field of integrated design management . 53 This may provide valuable
2.3.3.1).
4. To consider and research into holistic process change suitable for the Singapore
integrated project delivery (IPD) as proposed by AIA, 2007; see Appendix III);
contracts, e.g. IPD and lean construction principles (Abdelhamid, 2008) 54.
53 Sinclair (2008) commented that there are very few books devoted to the management of the
architectural design process p. , and design management is the discipline of planning,
organising and managing the design process to bring about the successful completion of specific
project goals and objectives Ibid., p. . The same rigour must surely be extended to the
integrated design process.
54 Lean construction refers to a production philosophy to minimize waste of materials, time, and
effort in order to generate the maximum possible amount of value. It requires the collaboration of
all project participants, client, consultants, contractors, facility managers, and users at early stages
of the project. This requires a new contractual arrangement where constructors and perhaps
facility managers play a role in informing and influencing the design (Abdelhamid, 2008).
55 In Lean-Led Design Rules of the Road , Teresa Carpenter proposed that lean principles be
130
During conceptual design, the owner is convinced
in fact feasible.
131
Appendix I
Source: Roadmap for the Integrated Design Process, p.107
132
“ppendix I Cont d
Source: Roadmap for the Integrated Design Process, p.108
133
“ppendix I Cont d
Source: Roadmap for the Integrated Design Process, p.109
134
“ppendix I Cont d
Source: Roadmap for the Integrated Design Process, p.110
135
An iterative process allows communication at
136
Appendix II
design as follows:
In How Designers Think , ”ryan Lawson , with inferences from earlier literature,
evaluation process; and often intertwines with these processes is the briefing process.
In the cognitive process, two types of thought processes are the most important in
attention to the demands of the external world whilst the latter is primarily concerned
with satisfying inner needs through cognitive activity which may be quite unrelated to
the real world Lawson, , p. 138). This appears to echo the reseach/analysis phase of
A skilled or mature designer, with an ability to control the direction of his/her thinking,
is able to steer the thinking towards a desirable outcome, i.e. production. The two major
categories of productive thoughts are convergent and divergent production, the former
being the outcome of largely rational and logical processes, whilst the latter being the
outcome of largely intuitive and imaginative processes. Design clearly involves both
convergent and divergent productive thinking, and studies of good designers at work
137
“ppendix II Cont d
have shown that they are able to develop and maintain several lines of thoughts in
Figure II-1 The whole host of issues to be considered in designing a window: one of the many
component and part of some inter-related systems in a building. Source: Lawson, 2005, p. 59
Lawson has also pointed out by way of the process of designing a window (Fig II-1) that
good design is often an outcome of integration. When dealing with a design as complex
as a building, in which there are many inter-related issues (or for Lawson, constraints),
there are many possibilities towards a well-integrated solution, and designers tend to
deal with it in two ways generation of alternatives and by employing several parallel
describe a parallel examination into different aspects of the same design, for example,
developing and sustaining many incomplete and nebulous ideas about various aspects
of their solutions Ibid., p. , and traits of creative thought processes are often
observed in both. At this juncture, it is also important to recognize that in the generation
138
Appendix II Cont d
of these alternatives, the designers are guided by their individual interests, approaches
legislation, clients, other consultants, and users (directly or indirectly); there are hence
many possible routes in the creative thought process (Ibid.). The generation of multiple
alternatives of thoughts allows the interplay between the values, issues, requirements,
(Ibid.). With reference to the integrated design process, this may possibly take place in
Intertwines in the production process is often, but not always, a parallel process known
as the briefing process (Ibid.). In theory, the idealized design process assumes that a clear
design brief is established before the design even started. This assumption is based on
the premise that the design end product is a solution to some sort of problems, or needs,
hence the design problems or needs have to be defined up front (Ibid.). In practice,
however, it is found that design problems are often never fully described at the start of
the design process. Even if it is described in details, it often changes and evolves, because
the design process actually begins to develop the brief as it formulates a solution (Ibid.).
This is because good design often deal with the multiplicity of the values, issues,
ideas which structure the scheme and around which the minor considerations are
thoughts allows the interplay of values, issues, requirements, problems and constraints
consultants, and sometimes builders and users. Such iterative process often helps to
139
“ppendix II Cont d
designers suggest that the early phases of design are often characterised by what
we might call analysis through synthesis. The problem is studied not in minute
detail but in a fairly rough way as the designer tries to identify not the most
important (to the client) issues, but the most crucial in determining form. Once a
solution idea can be formulated, however nebulous it may be, it can be checked
It is interesting that these and other designers studied who use the generation of
alternatives, often show them to their clients. This seems to become part of the
briefing process; a way of drawing more information out of the client about what
Eventually, the ideas produced will need to be evaluated, and decisions of which ideas
to be adopted and integrated into a holistic solution will have to be made. Designers
must be able to perform both objective and subjective evaluations and be able to make
judgements about the relative benefits of them even though they may rely on
So far, the designer has largely been described as a person. With the exception of small
scale projects e.g. single-family house, building projects usually involve many people in
a design team, comprising architects, who are likely to have team members focusing on
different aspects of the project, as well as civil & structural engineers, mechanical &
140
“ppendix II Cont d
electrical engineers, and possibly many other specialized consultants, such as quantity
This brings about a second characteristic of design in practice, which is vital to team-
based integrated design process: besides being a cognitive process, design is also a social
process, in which the rapport between group members can be as significant as their
”oth the individual specialist teams and the overall project team can be seen to
more time interacting with other specialist consultants and fellow architects, then
It is hence worthwhile to explore the notion of group dynamics. “ group acts not just as
a collection of individuals, but also in a manner somehow beyond the abilities of the
2) They develop a set of norms, which guide their behavior and activities;
norms developed over time, often through conflict resolution, it results in a common
perception of the group s goal and individuals acquiring and accepting roles within the
group, and these roles simultaneously often help to facilitate the business of the group
and become part of the folklore which binds the group together Ibid., p. .
141
“ppendix II Cont d
Many high-performing design practices are found to be also strong social groups,
formed after overcoming internal strives or external challenges. They developed shared
language and common admiration for previous design work Ibid., p. , and relied
heavily on the sharing of concepts and agreed use of words which act as a shorthand
for those concepts. Ibid., p. The intensity of the design process demands that such
shorthand be used during conversations. At the same time, the social nature of team
Many designers value continual engagement with the client, in the process developing a
trusting relationship with client. From the client s perspective, trust is needed because
building professionals are designers that clients expect to be protected from his or her
perspective, without trust, creativity and innovation in design is unlikely to take place,
doubted or rejected by the client, which undermines the very nature of the divergent
In big projects, client is often also represented by a group or committee. Needless to say,
client group or committee that experiences frequent changes in its members would suffer
142
“ppendix II Cont d
During the production process, it is noteworthy that good designers are able to sustain
several conversations with their drawings, each with slightly different terms of
reference, without worrying that the whole does not yet make sense. This important
ability shows a willingness to live with uncertainty, consider alternative and perhaps
even conflicting notions, defer judgement, and yet eventually almost ruthlessly resolve
and hang on to the central idea Ibid., p. 219). While such traits are valuable to an
individual designer, the ability to conduct design as a conversation becomes even more
1) Build up trust;
2) Identify the central elements of the design through a narrative process (Ibid., p.
267);
navigate from problem to solution. The parties come into the negotiation taking
different views and having different objectives but with a willingness to reach
shorthand to facilitate the intense iteration process in design. “t the same time,
such shared experience helps to forge social bond between the design team
members.
143
Appendix II (Cont d
The conversational nature of the design process is seen also in the negotiation between
problem and solution . This leads to the heart of the design process, which led Lawson to
state that:
So designers have the task of negotiating reconciliation between these two views
of the situation they are dealing with. The problem view is expressed generally in
the form of needs, desires, wishes and requirements. The solution view on the
drawings and visual representation is likewise engaged between the designer and
paying client, between fellow designers, and between designer and users. In an extensive
process, the conversation may also be engaged between the designer and builder, and
builders and manufacturers are advocated in the integrated design approach, and the
experience from KTPH appears to support such an advocacy. In the KTPH project, the
conventionally appointed contractors, being late comer on the project, did not enjoy the
57This conversation may also be understood as iteration loops Heiselberg and van der “a,
2010).
144
“ppendix II Cont d
benefits of early involvement and hence understanding the design objectives and
sensible to tackle the problems that imposed the most constraints, before
progressing to those with lesser constraints. This is supported by van der Aa,
Heiselberg and Perino s interative design model (Section 3.2 of this Appendix),
and validated through the examples examined for the KTPH case study: the site
layout and massing form and proportion was first determined in the masterplan
stage, followed by envelope design for the various blocks in the schematic and
early design development stage, before system design and component design in
What seems important to one client in one project may not be necessary so to
understanding is required.
Lawson has also written about the continuous and interacting relationship between
2. There is no one best solution to design problems many acceptable solutions are
possible, each proving more or less satisfactory to different client and users
58Design problems here may also be understood as design requirements , design constraints ,
design issues , and/or design challenges .
145
“ppendix II Cont d
5. Design solutions are parts of other design problems (Lawson, 2005, p. 122-123).
This leads to the need to involve stakeholders, experts from different disciplines, and key
decision makers in the iterative process, because problems often only emerged after
tentative solutions are proposed. This is especially the case for a large, complex project
The problem-solution model of the design process is also put forth by Michael Brawne
(2003), who sees a parallel in the cyclical design sequence in the Popperian59 sequence of:
corroborated solution which becomes the problem to the next sequence). It is important
to note that in the design process, the starting problem can occur both within and
outside architecture but more often than not manifests itself as a problem in architecture
irrespective of its origin…We start with a verbally stated problem but very soon have to
shift into non verbal-thinking ”rawne, , p.p. -35). This underscores the
fragmentary and inter-contradicting), which are initially describable only in words (and
tentative solutions multiple line of thoughts that are by necessity expressed in non-
verbal terms e.g. drawings, computer models, physical models , before it could be
59Named after Sir Karl Raimund Popper. In “ll Life is Problem Solving , the Popperian sequence
(PS1 TT EE PS2) was proposed as a model for scientific advancement, in which the degree
of truth in scientific theories are only true for its time TT, tentative theories further research
and processes (EE, error elimination) will always yield better theories. In such cyclical process,
scientific knowledge thus advances from lower grade problem situations towards higher grade
ones (PS1 to PS2).
146
“ppendix II Cont d
that integrates the host of solutions to the problems that had been recognized).
It is also noteworthy to note that in the design sequence P1 to P2, a great many initial
problems are self imposed and often arise from visual choices (Ibid., p. 259). He
”efore we use models in the tentative solution, in the design stage, we are
involved in problem selection. We cannot and do not solve all the problems
which exist at that time in that project…There are the demand set by the brief
It is the severity and nature of the self-imposed problems which are the test of
journeyman s task…Poetry and delight are the task of the master and arise from
ourselves which produces the greatest agonies and delight of design. ”rawne,
2003, p. 62)
What Michael Brawne has just described, is perhaps the secret to how architects have
rather universally been taught and practiced; the values first transferred from teacher to
nature a rather self-centred process, which presents a challenge to the integrated design
process (IDP), as IDP demands that architects fundamentally alter their role, to listen and
be open-minded to admit inputs from many other sources. But giving up control goes
147
“ppendix II Cont d
sustainability studio appears to reflect this, Many of the external enquiries requesting
for our involvement are projects that architectural concept design have been determined.
There is often a limit to what we could offer, especially in passive response to site and
On the other hand, there is a reluctance among the engineers to contribute in a more
have been conditioned to start thinking only after the architectural concept design had
been generated and handed off to them. The other common trait observed from M&E
engineers, perhaps reflecting the challenges they are confronted with, is the tussle
between the concern for under-performing design and the need for innovative
engineering approach which is often perceived as untested method , high risks , and
unknown liabilities . In addition, the disconnect between the engineers and the
problem. While engineers provide general design, the actual design and installation had
to be tendered out and worked on by the contractors and manufacturers who won the
tender, based on the actual product or construction method used. The opposing
positions between the clients (who wish to pay less) and contractors/manufacturers (who
wish to claim for more) often leads to adversities and disputes, with engineers caught
out between two parties. In the healthcare context, complexity in the M&E systems
Integrated design is not as easy as changing your shirt every day; old habits die
reactive for decades, because no matter how the architect designs the building,
they can still provide more or less adequate comfort by adding air-conditioning
tonnage. There are also the risks of trying new things; every departure from
148
“ppendix II Cont d
normal design practices, no matter how intelligent, runs the risk of a lawsuit if
things don t work out as planned. To make integrated design work, the team
often has to challenge prevailing codes. This is how progress is made, but it isn t
As a result, for the integrated design approach to be successful, it has to start with
mindset change and alignment from all stakeholders, including client, architect,
engineers, specialist consultants, users, and many other stakeholders (See Section 2.3.2 of
fostering collaborative spirit through a healthy, encouraging and trusting social process
and group dynamics as explored in Section 2.1 to 2.3 of this Appendix, and Section
2.3.4.2 of this dissertation. In addition, the team-based iterative process may be facilitated
The design iteration methodology is an emerging field, and this section examines some
2) Strategies for Integrative ”uilding Design Heiselberg and van der Aa, 2010)
Process IDP claimed that IDP contains no elements that are radically new, but
The salient point to highlight in the iiS”E IDP process is the presence of feedback loops
149
“ppendix II Cont d
Figure II-2 iiSBE Integrated Design Process. Source: iiSBE (Larsson, 2004)
The feedback loops in Figure II-2 illustrate the inter-activity between building envelope
design. Throughout the iteration, the focus is on the performance targets established for
a broad range of parameters and as consensus between designers and client (Ibid., p.p. 2-
1) Iterate the process to produce at least two, and preferably three, concept design
alternatives, using energy simulations as a test of progress, and then select the
structure… extra expenditures for one system, e.g. for sun shading devices, may
reduce costs in another systems, e,g, capital and operating costs for a cooling
system Ibid., p. .
150
“ppendix II Cont d
in Section 2.3.3.4 of the dissertation. The objective of the iteration is to achieve what they
They proposed that an integrated building concept can be defined to consist of three
parts: an architectural building concept, structural building concept, and an energy and
Figure II-3 Integrated Building Concept. Source: Heiselberg and van der Aa (2010).
151
“ppendix II Cont d
strategies (Ibid., p. 6, Table II-1), from macro to micro, from broad-based to specific
152
“ppendix II Cont d
Figure II-4 Iterative Process. Source: Heiselberg and van der Aa (2010).
Similarly, Heiselberg and van der “a propose that iteration loops (Figure II-5) are
expected to characterize each of the design phases, allowing tasks problems in Section
iterated taking into consideration input[s] from other specialists, influences from
context and society that provide possibilities and/or limitations to design solutions as
well as evaluates the solutions according to the design goals and criteria Ibid., p. .
Figure II-5 Iteration loops as proposed in Strategies for integrative building design van der
Aa, Heiselberg and Perino, . [This author is of the view that Coal in the diagramme is a
typological error and show read as Goal instead].
153
“ppendix II Cont d
integrated design is a systems approach [that] has the potential to create buildings with
lower first costs and large energy savings Ibid., slide , and that the fundamental
process of integrated design is the search for synergies. Synergistic strategies create
benefits greater than the sum of the individual design decisions Ibid., slide . Their
climate, building use, and site & building design (Figure II-6).
Figure II-6 ”uilding energy loads as presented in Rethinking the Design Process .
Source: Konstruct (2006).
1) Reducing energy load demand, say by 50% e.g. through good bioclimatic and site
response, adopts passive design strategies, right-sizing of user receptacle load,
etc;
154
“ppendix II Cont d
Figure II-7 “pproach to reduce energy consumption as presented in Rethinking the Design
Process . Source Konstruct , slide .
consumption to 25% of a typical, conventional design is plausible, and along the way
perhaps even resulting in cost saving in the system designs (Ibid.). This simple and
succinct approach is indeed an effective way to establish the right shared mindset
among the stakeholders, an important first step that leads to team visioning and setting
integrated design process, comprising: design topics, iterative process, energy topics,
and tools & data to find synergies (Figure II-8 and Figure II-9). While not explicitly
meet the diverse range of knowledge and skill sets needed for the problem definition,
The heart of the integrated design process…is the search for synergies between
two or more attributes of climate, use, design, and systems, that will result in
(Konstruct, 2006)
155
“ppendix II Cont d
Figure II-8 Components of integrated design process presented in Rethinking the Design
Process . Source Konstruct .
Figure II-9 The search for synergies between two or more attributes of climate, use, design, and
systems as presented in Rethinking the Design Process . Source Konstruct .
156
A BIM methodology seeks to adapt to the added
single-source model.
157
Appendix III
building information modeling (BIM) and integrated design, sustainable design and its
used to design and document a project, but is also used as a vehicle to enhance
informational technological (IT) platform for building design and documentation with
S/No. Event
1. ”IM is information about the entire building and a complete set of design documents stored in an
integrated database Ibid, p. [Italic emphasis by author].
2. “ll the information is parametric and thereby interconnected Ibid, p. [Italic emphasis by
author].
3. “ny changes to an object within the model are instantly reflected throughout the rest of the project
in all views Ibid, p. [Italic emphasis by author].
4. “ ”IM model contains the building s actual constructions and assemblies rather than a two-
dimensional representation of the building that is commonly found in CAD-based drawings
(Ibid, p.26) [Italic emphasis by author].
5. “ ”IM model can be holistically used throughout the design process and the construction
process. Ibid, p. .
6. BIM methodology allows
But more importantly, it entails an entire re-think in workflow in order to fully harness
its benefits (Table III-2). The main challenge being confronted in the industry, is not
technological in nature, but a resistance to work flow change due to mindset and attitude
(Deutsch, 2011, p. x; Figure III-1 and III-2). Since it needs to be approached as a change in
method and workflow Krygiel and Nies, 2008, p. 43), it shares many similarities with
the need for mindset change in integrated design, as presented in the next section.
158
“ppendix III Cont d
S/No. Event
1. 3D Simulation versus 2D representation (Ibid, p.34): permitting clashes of building
elements and components to be viewed in virtual 3D space on computer display.
2. Accuracy versus estimation (Ibid, p.34): By allowing the building design to be
constructed virtually before its physical implementation, ”IM adds a layer of accuracy
to both building quantities and qualities Ibid, p.p. -35).
3. Efficiency versus redundancy (Ibid, p. 35): By adding building objects to the design
once, instead of drawing the same object in different views, time saving is achievable.
4. Intelligent representation “ ”IM model contains the building s actual constructions
and assemblies rather than a two-dimensional representation of the building that is
commonly found in CAD-based drawings (Ibid, p.26) [Italic emphasis by author].
5. Project lifecycle “ ”IM model can be holistically used throughout the design process
and the construction process. (Ibid, p.27)
6. Integrated document As all of the drawings in a BIM model are placed within the
single, integrated database or model, document coordination becomes relatively
automatic (Ibid, p.38).
7. Design visualization: Since the model is in 3D, it can be viewed and turn around for
visual examination, unlike 2D drawings which are susceptible to subjective
interpretation and miscommunication, especially if lay persons (e.g. users) are involved
(Ibid, p.38).
8. Material database: Since BIM model is also a database of the virtual building, if the
models of building components and assemblies are created with their physical
properties, automation of scheduling and quantity take off can be achieved (Ibid, p.39).
9. Sustainable strategies: The building geometry from the model may be used internally
within BIM or exported for analysis to support sustainable design, e.g. energy modeling
and daylight modeling (Ibid, p.40).
10. Construction planning: Contractor familiar with BIM can utilize the model for
visualization, planning and coordination, to avoid errors and waste during
implementation. It may also facilitate digital workflow from design to fabricator, since
the information is all in 3D (Ibid, p.40).
11. Postoccupancy and facilities management: The BIM model may be utilized by building
owner and facilities managers for asset management and equipment tracking (Ibid,
p.40).
Figure III-1 Common erroneous perception is that BIM is primarily a technology change (left).
Instead, Deutsch (2011) argued that in reality, BIM is about sociological change, involving
practical, attitudinal, and behavioral changes. Source Deutsch (2011), p. x.
159
“ppendix III Cont d
Figure III-2 The business and technology cases for BIM and integrated design have already
been made. It is time to make the social case for firm culture, including working relationships,
interactions, and intelligence. Source Deutsch (2011), p. xi.
causes that give rise to the needs for integrated design and BIM are in fact quite the same:
specialization and fragmentation of the building knowledge and technologies, and hence
a need for integration. To support sustainable design, new specialized knowledge and
design layer e.g. solar analysis model, energy model, daylighting model have indeed
added additional design layers and complexity to the traditional physical design model,
documentation (Ibid, p.p. 46-52; Figure III-3). All intent and purpose of BIM is to
Figure III-3 Layers of design information. Source: Krygiel and Nies (2008), p. 55.
160
“ppendix II Cont d
becomes truly owned in practice, higher productivity, higher quality work, and new
possibilities, e.g. integrated design and sustainable design become attainable (Deutsch,
Figure III-4 BIM Roadmap. Source: Krygiel and Nies (2008), p. 52.
161
“ppendix III Cont d
structures and practices into a process that collaboratively harnesses the talents and
insights of all participants to optimize project results, increase value to the owner, reduce
waste, and maximize efficiency through all phases of design, fabrication and
construction “I“ IPD Guide, . It has an ambitious aim to not only incorporate
design into its process, but goes beyond that to attempt to bridge the gap between design
In the IPD process map (Figure III-6), the full project team is identified and involved
much earlier in the process, including the builders and fabricators. More time is spent in
the design phase, to allow team-based integrated design process to take place, with ideas
162
“ppendix III Cont d
supported by and tested out using a variety of tools, e.g. sketches, technical calculations,
approval) and agency (authority approval) phases require less time based on a set of
Although it is not a mandatory tool, BIM is explicitly stated and promoted in IPD. Figure
III-7 by Autodesk, a BIM software vendor, illustrates the utilization of BIM throughout
IPD represents a substantial industry-wide process change, and its principles, values and
Figure III-7 Integrated Project Delivery with BIM. Source: Autodesk (2008).
163
The process and science of building design has
164
Appendix IV
Peter Schubert
Healthcare Architectural
RMJM Hillier Sung Won Lee
Consultant
Noah Burwell
Medical Planning Research (MPR)
Medical Planner Ray Skorupa
International
Soon Chern Yee
Civl & Structural Engineer CPG Consultants Pte Ltd Tan Swee Keng
Sumay Tan
Toh Yong Hua
Mechanical Engineer CPG Consultants Pte Ltd V Devaraja
Heng Chen Han
Wong Lee Phing
Electrical Engineer CPG Consultants Pte Ltd
Melvin Yap
Green Building Consultant Total Building Performance Team Dr Lee Siew Eang
Landscape Consultant Peridian Asia Pte Ltd Glenn Bontigao
Yeo Tiong Yeow
Quantity Surveyor CPG Consultants Pte Ltd Tan Hui Choo
Raymond Koh Kok Yong
Interior Design Consultant Bent Severin & Associates Pte Ltd Grace Soh, James Wong
Facade Consultant Aurecon Singapore (Pte) Ltd Lily Low, Sigmund Mendiola
Wayfinding Consultant Space Syntax Australia PTY Ltd Martin Butterworth
Signage Consultant Design Objectives Pte Ltd Ronnie Tan, Lawrence Tong
165
What is this mysterious label and what does it
Barbra Batshalom
166
Appendix V
A. Based on Whole System Integrated Process (WSIP, 2007), the process stages in IDP may be categorized
as follows:
Stage Elements
1. Team Formation Fully engage Client in the design decision process.
“ssemble the right team.
Key attributes in team formation is teachable attitude members come on board not as experts
but co-learners.
2. Visioning “lign team around basic “spirations, a Core Purpose, and Core Values.
3. Objectives Setting Identify key systems to be addressed that will most benefit the environment and project
Commit to specific measurable goals for key systems
Compile into a Sustainable design brief
Key attributes in objective setting is to involve all participants, including the main financial
decision maker, not unempowered representative. Also, identify champions for the objectives
and issues.
4. Design Iteration Optimization of the design of systems
Key attributes in objective setting is to understand and make best use of key systems in
relationship to each other, to the goals, and to the core purpose , and Iterate ideas and systems
relationships among team with all participants, including the main financial decision maker.
5. Construction & Follow through during the Construction Process.
Commissioning Commission the project.
6. Post-occupancy Feedback Maintain the system.
Loops Measure performance and respond to feedback - adjust key aspects of the system accordingly.
B. Based on Roadmap for the Integrated Design Process (Roadmap IDP, 2007), team organization are
compared between conventional and integrated design team:
1.
2.
Q Which one do you think better describe KTPH design/project team organization? Answer (1 or 2): _______
167
“ppendix IV Cont d
C. Based on Whole System Integrated Process (WSIP, 2007), team organization are compared between
conventional and integrated design team:
1.
2.
Q Which one do you think better describe KTPH design/project design process? A: ______________
D. Are you familiar with the following integrated design/whole design process or methologies:
168
“ppendix IV Cont d
169
“ppendix IV Cont d
170
“ppendix IV Cont d
171
“ppendix V Cont d
172
Good design, that is evidence-based, does not cost
Bryan Lawson
173
Appendix VI
had facilitated the following benefits supported by the following evidence-based design
studies:
The biophilia hypothesis suggests that there is an inborn affinity within humankind with
nature and living systems, including plant life, animals, as well as climatic elements e.g.
the sun and natural light and warmth, breeze, sound, and so on (Wilson, 1984; Kellert et
al, 1993; Kellert, 2004). The hypothesis has found support in parallel studies in the field
findings is, not only is humankind aesthetically attracted to nature and living systems,
the sensing of with these features is also found to have positive effects on human
functioning and reduces stress (Bell, 2001; Bechtel, 2002). According to Ulrich (2002), the
healing properties of nature and natural systems have long been known, but have been
recently have nonetheless strengthened the case for bringing nature into healthcare
Research has shown that stress and psychosocial factors can significantly affect patient
health recovery (Ulrich, 2001; Dellinger, 2010). Since human responds psychologically
and physiologically to nature and landscape positively (Ulrich, 1986), integrating nature
174
Appendix VI Cont d
and landscape into healthcare built environment e.g. through the notion of the healing
garden (Ulrich, 1999, 2002; Shermana et al, 2005), or simply giving access to view
through window to nature and natural system have led to better postoperative outcome,
including the need for less pain medication, shorter lengths of stay, and few minor
Dellinger, 2010).
designers plan a healthcare facility, they need to make actual nature, such as healing
studies suggested the use of water features as a positive distraction, even briefly, that
cause positive emotional response (Joseph, 2006). Figure 3.3 and 3.4 illustrate the
various ways in which KTPH had integrated nature, landscape and water feature
Figure VI-1 View to nature: Yishun Pond viewed from the Central Courtyard.
Source: CPG Consultants Pte Ltd
175
“ppendix VI Cont d
Figure VI-2 Private seating corner around water as therapeutic modality: Courtyard at Basement
1 in Khoo Teck Puat Hospital featuring a small landscape pond. Source: CPG Consultants Pte Ltd
evaluations of four hospital gardens in California revealed that nurses and healthcare
workers are able to achieve pleasant escape and recuperate from stress by using the
gardens (Cooper-Marcus and Barnes, 1995). Providing windows with view also help
staff stay oriented with regards to time of day and weather condition, achieving better
well-being (Dellinger, 2010). Studies also showed that daylight penetration improves
nursing productivity (Rechel and McKee, 2008). In support of this, all wards in KTPH are
Studies have shown that patient recovery and well-being are enhanced by social support
and family care (McCullough, 2010, p.82). As family members providing care and
support to the patient likewise experience stress and anxiety, it is important that their
well-being is also addressed. Post-occupancy studies have revealed that patients family
who use hospital gardens also experienced positive mood change and reduced stress, as
well as higher satisfaction with overall quality of care (Whitehouse et al., 2001).
176
“ppendix VI Cont d
cost of delivering healthcare services (Ulrich, 2002), hence also enhancing economic
nursing clinicians found that external space is important to recruitment (p. 17), retention
(p. 22) and performance of nursing clinicians (p. 27). These suggest that access to and
The above benefits with support from evidence-based studies strongly suggest that
wherever possible, natural and landscape elements should be integrated into the design
outcome.
Spatial disorientation causes stress, and as a result negatively impact patients healing
outcome and staff working in healthcare environment (Ulrich et al, 2004). The need to
give directional information by other than front desk information staff has also resulted
in hidden costs to many hospitals (ibid.). Integrated and holistic way-finding systems
In addition to providing greenery for human well-being, the central courtyard in KTPH
simplifies way-finding by enabling building users to relate to the lush central greenery
through external corridors and ample exterior windows from within the rooms (Figure
VI-4). Escalators and lift lobbies are also opened into the central courtyard, providing
users with a pleasant visual cue to orientation. Open circulation system are brightly lit,
and public furniture provided for activity and rest are placed to face the courtyard to
177
“ppendix VI Cont d
Figure VI-3 Easy wayfinding: External corridors surrounding the Courtyard are brightly lit,
easy to orientate and laced with landscape to create a biophilic environment.
Source: CPG Consultants Pte Ltd)
Figure VI-4 Public furniture with good access to the Courtyard and Yishun pond views.
Source: CPG Consultants Pte Ltd
178
Figure VI-5 Courtyard at Ground level in Khoo Teck Puat Hospital is filled with lush sustainable
local plant types to achieve evidence-based supportive environment for patients, staff and visitors.
Source: CPG Consultants Pte Ltd
179
In integrated design, buildings aren t seen as one-
Randy Deutsch
180
Appendix VII
KTPH was designed to be served by chilled water central plant room system with 5
numbers of 900Ton centrifugal chillers served with AHUs and FCUs. Heat recovery
systems were used to reduce energy loss. The individual efficiencies of the air-
The plant room efficiency was benchmarked against Singapore Standard SS530, under
which the minimum efficiency of the plant room was 0.782kw/Ton. The KTPH design
was hence 20.8% more efficient. Under SS530, the cooling tower efficiency was
To conserve energy, high-efficiency T5 lighting with electronic ballasts was used for
general lighting, along with other high-performance, high-efficient lighting. The total
design wattage was 1,340.5kW compared to 1,463kW reference design, i.e. a saving of
8.4%.
181
“ppendix VII Cont d
The mechanical ventilation system of the Basement 2 carpark is monitored with CO2
sensor. This conserves energy by ensuring that the mechanical ventilation system was
Wherever possible, the common areas were designed to ventilate passively, through
natural ventilation:
conditioning
All lifts in KTPH utilise variable-voltage, variable-frequency (VVVF) motor drive to save
All escalators were embedded with motion/step-sensor to conserve energy when traffic
volume is low.
1. Heat pipe
182
Water is essential to life. It is hygienic, aesthetic,
Stephen Verderber
183
Appendix VIII
Water efficient fittings rated based on Singapore Public Utilities Board s PU” Water
Efficiency Labeling Scheme (WELS) were used. Most of the fittings were rated as
excellent , as follows
Fittings without rating (mostly special medical equipment): 642 units (18.4%)
Water meters were installed to monitor the portable water usage. The water meters were
Condensate water from AHU was collected and used as cooling tower make-up water.
Besides helping to reduce the amount of make-up water needed, the lower water
Rainwater collected within the KTPH site was fed to Yishun Pond, adjacent to the site.
The raw water (non-portable) from Yishun Pond was used for landscape irrigation in
KTPH, to reduce consumption on potable water. Newater, water recycled from sewage is
184
Give all building occupants environmental comfort
levels.
Bryan Lawson
185
Appendix IX
The air-conditioned spaces were designed to allow for cooling load variations due to
thermal comfort. The indoor air temperature was designed to be within 22.5°C and
With acoustic consultants advice, the ambient sound level of KTPH was designed to
between 40dB and 50dB in all occupant areas. The measures included were:
Walls, partitions and doors specified to STC 35dB, 40dB, 45dB and 50dB
0.5;
All wall perforation and duct penetration sealed with approved details to prevent
sound bridge/leak;
186
“ppendix IX Cont d
UVC Emitters60 was installed in the supply air duct just after the cooling coil, to kill all
pathogens. This improved the indoor air quality and helps to keep the cooling coil clean.
The AHU coils were pre-treated with titanium dioxide (TiO2), an anti-bacteria, anti-
odour and self-cleaning agent to eliminate bacteria and mould growth in the cooling
coils. As a result, it reduced the need for cleaning, as well as risk of sick building
syndrome.
Figure VIII-1 Schematic diagramme of a typical AHU in KTPH, showing the locations of UVC
emitter, radiometer and CO2 sensor. Source: CPG Consultants Pte Ltd
60UVC refers to a type of ultraviolet (UVC) energy. The "C" wavelength is the most effective
germicide in the UVC spectrum. UVC Emitters are devices that generate UVC rays to kill germs.
187
In the service of healing people, healthcare
Alexis Karolides
188
Appendix IX
Vacuum tube solar thermal system is utilised to generate the hot water usage
requirements of the hospital. The solar thermal system and solar heat pumps produce
was designed to fully meet the hot water requirements of the hospital (21,000 litres/day).
This resulted in a saving of 780kWh/day of electricity and the space for boiler was
eliminated.
Figure X-1 Vacuum tube solar thermal system in KTPH is used to generate hot water
Source: CPG Consultants Pte Ltd
Figure X-2).
189
“ppendix IX Cont d
Figure X-2 Photovoltaic system installed at the rooftop of KTPH to maximise solar exposure
and electricity output. (Source: CPG Consultants Pte Ltd)
essentially an ecologically self-sustaining pond that blended into the landscape. Besides
enhancing the environmental quality, it was also educational in promoting the concept
of sustainability.
The filtration of the Eco-pond was powered by a light mechanical pump. A diverse range
of marginal and water plants and small fishes form the eco-system, but only small fishes
were used, so that the system was able to handle the waste generated.
The water supply of the pond was from rainwater collected from the roof, filtered by the
roof garden. Excess water was fed to the water-efficient irrigation system.
190
“ppendix IX Cont d
2. Siphonic rainwater discharge system to reduce pipe size, hence reduce space
20%.
5. Composting machine was used to process food waste into fertilizer for roof and
food gardens.
191
If we are to understand and build upon the
Construction Phase
192
Appendix X
The integrated design effort continued even during construction. While the main
structure and architectural work was in progress, one of the areas of design focus for the
KTPH HPC and the building professionals was place-making in the social and
natural gathering place with the right look and feel to put people at ease when they
come into the hospital grounds…The hospital grounds should offer a healing
environment for the patient s family members to comfort each other. Spaces need to be
designed for events to happen CPG file archive . CPG “rchitect Pauline Tan recounted
that more than twenty locations were identified, with provisions made for lighting,
power point and routing for cables, LAN, water point, audio system with pipe-in music
wherever possible, ventilation, thermal comfort (e.g. spot cooling of roof terraces
presented in Section 4.2.1) and acoustics, mobile art and banners etc.
193
“ppendix XI Cont d
In interior design, artworks and images from the lush greenery in KTPH s previous
premise (AH) were displayed (Figure XI-1), to create positive, therapeutic impression
(verderber, 2010, p. 132). For example, the lit ceiling panel of the lift car. This again
demonstrated collaboration between the medical staff with intimate memory of AH and
The integrated, whole-system thinking went beyond the close collaboration between
medical and building professionals. “rchitect Lim recalled, During the construction of
Pond. At that time there was no budget for any landscaping works on the pond. KTPH
adopted the Yishun pond and convinced other government agencies through their
landscape programme), and PUB (ABC Waters) to co-finance the Yishun Pond
rejuvenation works for the community and patients. CPG Consultants and Peridian Asia
were also appointed to carry out an integrated landscape design involving multiple
agencies for the boardwalk, tower, overhead bridge and landscape around the Yishun
Pond that also connects well with the KTPH landscaped area. Though the hospital was
operational in 2010, the comprehensive healing environment was fully realized with the
for community benefits was achieved through a willingness to collaborate amongst the
governmental agencies, brought about by KTPH s CEO Liak s social influence and skills.
194
[G]reen building rating systems and other practice
design process."
195
Appendix XII
the Singapore national green rating system, was used as a tool to guide the green
building design for KTPH. It was certified as Green Mark Platinum in 2010, the highest
award under the BCA Green Mark Scheme. The assessment criteria of GM NRB 3.0 is
consideration for GM NRB 3.0, requiring a minimum score of 30 points, while all the
qualities and other green features) must achieve a minimum score of 20 points in order
to achieve the minimum score of 50 points, which is mandatory for Singapore since 2008.
KTPH achieved a score of 71.35 points for energy efficiency measures (Figure XII-2), out
of which GM NRB 3.0 accords a maximum of 50 points. The design consumes 36.4% less
energy then the baseline reference model. Under GM NRB3.0, the design also scored
2. Air-Conditioning System
4. Natural Ventilation
On the other hand, it scored a low 4.69 out of a total of 20 points (Figure XII-2) in the use
of renewable energy. Solar thermal for hot water and photovoltaic panel for electricity
Maximum scores were also achieved for many other categories, including Greenery ,
which is a main feature in KTPH. Categories where less than maximum scores were
of 14), and indoor air pollutants (1 out of 2). The score indicates that there are certainly
196
“ppendix XII Cont d
Figure XII-1 BCA Green Mark Non-Residential Building Version 3.0 Assessment System.
Source: Building Control Authority (BCA), Singapore.
197
“ppendix XII Cont d
Figure XII-2 KTPH s ”C“ Green Mark Energy Efficiency Score under NRB 3.0 Scoring System.
Source: CPG Consultants Pte Ltd.
198
Passive Mode requires an understanding of the
Ken Yeang
199
Appendix XIII
strategy, in order to balance the various needs: reduce energy usage, health and safety
e.g. infection control, human comfort, and meeting policy requirements e.g. subsidized
patient wards, have been discussed in Section 1.5.1. Due to its benefits, natural
In his dissertation, Wu (2011) conducted post-occupancy survey over three hospital with
ventilated wards, namely, KTPH, completed in 2010; AH, built more than 70 years ago in
1934; and CGH, built more than 14 years ago in 1997 (Wu, 2011). It was found that
patients in the air-conditioned (for private ward patients) and naturally ventilated (for
subsidized patients) wards had equally high acceptability of the thermal environment in
KTPH Figure . . ”oth CGH and KTPH met the “SH“RE -2010 thermal
satisfaction requirement for their air-conditioned and naturally ventilated wards ibid.
p. . With regards to nursing clinicians, Wu s survey found that none met the “SH“RE
55-2010 standard requirements, but KTPH provided conditions that satisfied more
clinicians (77.4%) then CGH (64.3%) and AH (30.8%)(Figure XIII-1; ibid, p. 76). Wu
attributed this to the higher activity level performed by nursing clinicians as compared
Interestingly, Wu also found that there is insignificant difference in the satisfaction level
between patients in the naturally ventilated ward and the air-conditioned ward (Figure
XIII-2; Ibid., p. 101). This finding validated that with thoroughly considered bioclimatic
design, it is viable to design healthcare wards using NV, with ventilation at nurse station
200
“ppendix XIII Cont d
integrated sustainable design strategies, encompassing site planning, venturi effect of the
courtyard, landscaping, building shape and layout, building envelope, façade design,
central atrium, interior design, and partial energy recovery through recycling of cooled
Figure XIII-2 Nursing Clinician Acceptability of Thermal Environment in CGH and KTPH.
Source: Wu, 2011, pp. 76.
201
“ppendix XIII Cont d
Table XIII-1 Sustainable Design Strategies Employed in Khoo Teck Puat Hospital for Thermal
Comfort in Naturally Ventilated Area. Source: Wu, 2011, p. 130-131
202
“ppendix XIII Cont d
Table XIII- Cont d Sustainable Design Strategies Employed in Khoo Teck Puat Hospital for
Thermal Comfort in Naturally Ventilated Area. Source: Wu, 2011, p. 130-131
203
Often, additional organizational social benefits is
204
Appendix XIV
KTPH
1.0 Post-Occupancy Survey (Sng, 2011)
being a Green Mark Platinum certified green building, KTPH has provided for natural
and social environments well to a reasonably large extent p. . From among sixteen
features, the most noted and welcome features of KTPH, in ascending order, are (Sng,
Figure XIII-1 Number of times being mentioned as a group description (constructs) and number of
times being chosen as a top priority group. Source: Sng, 2011, pp. 60.
205
“ppendix XIV Cont d
1. Natural Scenery
environment .
The integration of nature into the KTPH premise, an outcome due to the biophilic
approach taken by KTPH and its design team, was found by Sng62 to be the most well-
like feature. It was also deemed to be the most important among all the features. In
addition, the survey also found that people prefer the positive feeling that nature offers,
rather than manicured gardens Ibid., p. . This validates both the biophilia
hypothesis (Wilson, 1984; Kellert et al, 1993; Kellert, 2004; see also Appendix V), as well
as the KTPH CEO Liak Teng Lit s personal belief. ”ased on CPG “rchitect Jerry Ong s
account, besides the aforesaid reason, Liak also believed that by using local plant types
in a natural setting, it require less intervention and efforts for the plant ecology to thrive.
This is not only more ecologically friendly, but results in lower maintenance as well
Social or communal activities are the next well like feature in KTPH, indicating that its
premise is well provided for people Sng, , p. . The association of its premise
with experience such as With Families and Friends , Recreational “ctivities , Walking
and Viewing and Relax may imply that people enjoy the premise as a social setting, as
design principles with regards to well-being for family, visitors and public (Whitehouse
et al., 2001; see 1.3 in Appendix V) and well-being for clinicians and staff (Cooper-
Marcus and Barnes, 1995; Dellinger, 2010; See 1.2 in Appendix V).
62 Sng used multidimensional scaling (MDS) to plot the data collected for interpreting the results.
206
“ppendix XIV Cont d
Sng also found that these wellness dimensions of World Health Organizations Quality
of Life WHOQOL are in fact missing from ”C“ Green Mark rating system Ibid., p.
not the current purpose of Green Mark rating system. Nonetheless, it also indicates that
independently from the Green Mark rating system; in the case of KTPH, it was through
open up its premise to connect, engage and be enjoyed by its neighbourboods and
healthcare programmes. The connectivity created between KTPH, Yishun Pond and its
programmes, etc to make use of KTPH s premise. Fostered by KTPH s biophillic, user-
friendly public spaces and amenities, the increasing community participations since the
207
“ppendix XIV Cont d
References:
1 http://www.ktph.com.sg/main/pages/1443 [online] <Accessed on 31.12.2011>.
208
For more than 99 percent of human history people
regulated world.
209
Appendix XV
environment with Ponggol Pond and the Yishun natural and community context, the
Some Yishun residents, including retired farmers in the Yishun community (Wu, 2011, p.
108) had volunteered to tend to the rooftop vegetable and fruit gardens at KTPH (AHa!
Mar-Apr 2010, p. 11; Figure XIV-1, XIV-2). One key volunteer with green fingers, 68-year
old Mdm Lim Chew Eng, who also tends to community farm in Yishun town, shared her
experience and help create an urban farm in the hospital (Ibid.). The produce such as
the hospital kitchen, and composted food waste from the hospital kitchen provided
KTPH s Chief Gardener , Rosalind Tan, who oversees the volunteer gardeners
said that residents were keen to get involved and brought their friends along. She
welcomes them and others too…Urban farming on the rooftop not only provides
the hospital s kitchen with an organic food source for our patients, it also reduces
the temperature of the building and involves the community in caring for our
2010, p. 11)
210
“ppendix XV Cont d
gardens, patios, balconies, terraces (Figure XIV-4), courtyards (Figure XIV-3), and water
as therapeutic modality (Figure 3.3, 3.18, 3.19), etc that Verderber (2010) has
recommended for the hospital environment, with KTPH providing some examples.
Figure XIV-2 Yishun resident volunteers led by Rosalnd Tan (Second from right) working on the
Urban Farm above KTPH. Source: Alexandra Health Newsletter AHa! Mar-Apr 2010, p. 11
211
“ppendix XV Cont d
Figure XIV-3 Interrelationships of gardening in semi-open space, people and climate in tropical high-
rise housings. Source: P. Kong in Bay and Ong, 2006, p. 75.
In his thesis, Kong suggests that gardening, people, and environment form a
75). As participants tend to the KTPH urban farm with care and interest, creating a sense
of community ownership, the plant in turn improve the environment, the activity
increases, improving the casual knowing of neighbours and sense of community, and
thus in turn encourage more interest in gardening [and/or farming] Ibid., p. . Nature
Figure XIV-4 Rooftop gardens, balconies, patios at KTPH help reduce the indoor temperature and
mitigate urban heat island effect. Source: CPG Consultants Pte Ltd
212
“ppendix XV Cont d
KTPH adopted the Yishun pond in 2005 under Public Utilities ”oard PU” s Our
Waters Programme , and participated actively in plans to transform it into a green lung,
e.g. organizing regular pond clean-ups of areas around the pond (AHa! Sep-Oct 2010, p.
2)63. With the opening of KTPH, through a collaboration between National Environment
Agency (NEA), PUB, National Parks Board (NPB) and Alexandra Health KTPH s
holding company), improvement work was carried out at Yishun Pond to turn it into an
intergenerational, health promoting garden that will be integrated with the hospital
(Ibid.).
It provided more and better park facilities for residents living in the surrounding Yishun
communities to exercise and interact. Marshlands created along the shore softens the
water edge and improve water quality by filtering pollutants through the use of aquatic
promenade was built to connect KTPH s central courtyard to the garden Ibid. ,
providing more opportunities for KTPH to spread health promoting messages among
initiative to improve the quality of water and life by harnessing the full potential of our
waterbodies…by integrating the drains, canals and reservoirs with the surrounding
environment in a holistic way “”C Guidelines, p. . Under the “”C programme, built
environment that harness water sensitive urban design and sustainable drainage
principles may be ABC certified, and KTPH is ABC-certified in 2010. The following
1. Planter boxes and green roofs detain and treat 12% of rain water run-off that is
213
Appendix XV (Cont d
2. A green wall and terraced landscape enhances the lushness of the area while
resting and seating facilities along streams and water features bring people closer
to water.
3. Integration with the nearby Yishun Pond, with extensive plantings providing a
tranquil and scenic environment for the hospital s patients and visitors while
The core KTPH management and team migrated from Alexandra Hospital (AH), 66
was a senior executive at AH s operations department, and since 2000, she has led the
trees and shrubs, aromatic flowers, water features even a butterfly trail that boasts 100
species. Ibid. For her contributions towards environmental sustainability, she was
AH s garden is popular on weekends, with former patients bringing their families there
for a stroll, and members of nature societies using it as a study ground Ibid. Table XV-
1)
214
“ppendix XV Cont d
Table XV-1 Nature “ctivities and Reports of “lexandra Hospital s garden and butterfly sighting.
Date. Event
30.07.2005 Perry, M. Alexandra Hospital opens new garden of medicinal plants. Channel News Asia
(http://www.wildsingapore.com/news/20050708/050730-1.htm#cna1)
16.10.2005 Perry, M. Alexandra Hospital garden has plants that heal, thrill or kill. Channel News
Asia (http://www.wildsingapore.com/news/20050708/050730-1.htm#cna1)
20.03.2007 Baron, G. Locally Extinct Butterfly Sighted at AH! Singapore Nature Society Butterfly
Interest Group (http://bignss.blogspot.com/2008/03/new-species-sighted-at-
alexandra.html)
04.04.2008 Wong, W. Euphorbia in Bloom @ Alexandra Hospital & Other Happenings. Garden with
Wilson (http://gardeningwithwilson.com/2008/04/04/euphorbia-in-bloom-
alexandra-hospital-other-happenings/)
27.07.2008 Khew, S. K. Butterfly Photography at our Local Parks. Butterflies of Singapore
(http://butterflycircle.blogspot.com/2008/07/butterfly-photography-at-our-
local.html)
28.07.2008 Commander. Shooting at Alexandra Hospital Butterfly Trail. Butterfly Circle
(http://www.butterflycircle.com/?p=17)
12.11.2008 Wong, W. “lexandra Hospital s Garden Party. Garden with Wilson
(http://gardeningwithwilson.com/2008/11/12/alexandra-hospitals-garden-party/)
15.02.2009 Mantamola. Butterfly Park @ Alexandra Hospital. Manta blog
(http://mantamola.blogspot.com/2009/02/butterfly-park-alexandra-hospital.html)
28.05.2009 National Parks Board. Creating Butterfly-Friendly Habitats.
29.05.2009 (http://www.nparks.gov.sg/cms/index.php?option=com_content&view=
article&id=172&Itemid=129)
05.12.2009 ItchyFingers. A Visit to the Hospital.
(http://myitchyfingers.wordpress.com/2009/12/05/a-visit-to-the-hospital/)
16.02.2010 Seah, J. Alexandra Hospital Butterfly Trail, S'pore. Singapore Fauna and Flora
(http://www.flickr.com/photos/j_for_joyce/sets/72157623471951042/)
31.03.2011 Khew, S. K. and Tan, E. Return of a Magnificent Giant. Butterflies of Singapore
(http://butterflycircle.blogspot.com/2011/03/return-of-magnificent-giant.html)
02.04.2011 Lim, S. et al. Alexandra Hospital Butterfly Trail. Informal Macro Outing Group
(http://npssimog.blogspot.com/2011/04/82011-alexandra-hospital-butterfly.html)
22.07.2011 Starmer, C. F. Adventures with curiosity and learning.
(http://frank.itlab.us/photo_essays/wrapper.php?jul_22_2011_ahbt.html)
30.11.2011 Gan, W. C. Singapore s Winged Wonders. Singapore Kopitiam
(http://www.singaporekopitiam.sg/places-and-heritage/places/wildlife-and-
nature/item/1001-singapores-winged-wonders)
12.02.2012 Mariano, M. Hospital Butterfly Trail. (http://flickeflu.com/set/72157626141292182)
Unknown Wong, C. P. Alexandra Hospital Butterfly Garden
(http://www.pbase.com/gohorses/alexandra_hospital_butterfly_garden)
Unknown Regular guided walk at AH by Butterfly Interest Group
(http://butterfly.nss.org.sg/home/butt_walks.htm)
215
“ppendix XV Cont d
butterfly enthusiast based in Singapore (Khew, 2008)68, it was a project started in 2002 led
by Rosalind, an occupational therapist who had drawn from her experience that a
butterfly garden could help in a patient's recovery, validating the biophilia hypothesis
and evidence-based studies on positive distraction (Lahood and Brink, 2010, Delinger,
2010):
Butterflies have so many colours and patterns. Seeing them gives patients
optimism and distracts them from their illnesses,' she said (Khew, 2008)
Vast areas of KTPH were earmarked for landscaping to encourage the creation of
sought to increase the indigenous wild life biodiversity by introducing native species of
plants in the hospital s landscaping. Wu, , p. with life-long passion from staff
member like Rosalind Tan, its environmental philosophy and stewardship looks likely to
bring new success, as the management had set a biodiversity target for KTPH:
100 species of butterflies, birds, fishes, flowering plants, fruit trees, native trees,
edible plants and fragrant plants. Yes, all 800 of them (Ong, J, 2010)69
Such ambitious objectives are not likely to be set without a collective will driven by a
Batshalom and Reed (see Section 2.3.2 and Figure 2.3). To succeed, however, it also
necessitates a process of value sharing and transfer, from KTPH to the building
professionals, to ensure that the design of the built environment outcome supports such
68 Khew, S. K. aka Commander, leads the butterfly interest group ”utterflies of Singapore . He is
also this authors colleague in CPG. Source http://www.butterflycircle.com/forums/
showthread.php?t=6993
69 Ong, J is the architect involved in the KTPH Project. Source: http://blog.cpgcorp.com.sg/?p=69
216
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Chapter 1:
Upper: Schettler, T. From Medicine to Ecological Health , in Guenther, R., Vittori, G.
(2008), Sustainable Healthcare “rchitecture , John Wiley & Sons, New Jersey, p. 68
Lower: Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture , John Wiley &
Sons, New Jersey.
Chapter 2:
Upper: Reed, B. Integrative Design Process: Changing Our Mental Model , in
Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture , John Wiley &
Sons, New Jersey, p. 133.
Lower: Zimmerman, A. Integrated Design Process Guide, CMHC, Canada, p. 4.
Chapter 3:
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Teck Puat Hospital , th Design & Health World Congress 2009, Singapore, 25-27
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Lower: Verderber, S. , Innovations in Hospital “rchitecture , Routledge, New
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Chapter 4:
Upper: Or, D. In: Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture ,
John Wiley & Sons, New Jersey, p. 135.
Lower: Heinfeld, D. In: Yudelson, J. , Green Building through Integrated Design ,
McGraw-Hill, USA, p. 69.
Chapter 5:
Upper: Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture , John Wiley &
Sons, New Jersey, p. 154.
Lower: Berkebile, B. In: Guenther, R., Vittori, G. (2008), Sustainable Healthcare
“rchitecture , John Wiley & Sons, New Jersey, p. 19.
Appendix II: 7Group, Reed, B. (2009), The Integrative Design Guide to Green ”uilding:
Redefining the Practice of Sustainability , John Wiley & Sons, New Jersey, p. 68.
Appendix III: Krygiel, E. and Nies, B. (2008), Green BIM: Successful Sustainable Design
with ”uilding Information Modeling , Wiley Publishing, Indianapolis, p. 32.
Appendix IV: Krygiel, E. and Nies, B. (2008), Green ”IM: Successful Sustainable Design
with ”uilding Information Modeling , Wiley Publishing, Indianapolis, p. 53.
Appendix V: Batshalom , B. In: 7Group, Reed, B. (2009), The Integrative Design Guide to
Green ”uilding: Redefining the Practice of Sustainability , John Wiley & Sons, New Jersey,
p. 16.
Appendix VI: Lawson, B., (2005), Evidence-based Design for Healthcare, Business
Briefing: Hospital Engineering & Facilities Management, Issues 2, p. 27.
Appendix VII: Deutsch, R. (2011), ”IM and Integrated Design: Strategies for “rchitectural
Practice , John Wiley & Sons, New Jersey, p. 138.
Appendix IX: Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture , John
Wiley & Sons, New Jersey, p. 119.
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Appendix XI: Krygiel, E. and Nies, B. (2008), Green ”IM: Successful Sustainable Design
with ”uilding Information Modeling , Wiley Publishing, Indianapolis, p. 56.
Appendix XII: Keeler, M., Burke, M. (2009), Fundamentals of Integrated Design for
Sustainable Building , John Wiley & Sons, New Jersey, p. 231.
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Ong, B. L. (2006), Tropical Sustainable Architecture: Social and Economic Dimensions ,
Architectural Press, Oxford, p. 53.
Appendix XIV: Guenther, R., Vittori, G. (2008), Sustainable Healthcare “rchitecture , John
Wiley & Sons, New Jersey, p. 119.
230