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by the Netherlands Board for Hospital Facilities on 7 October 2002 by the Minister for Health, Welfare and Sports on 19 November 2002
General hospital building guidelines
CONTENTS 1. 2. 2.1 2.2 2.3 3. 3.1 3.2 3.3 3.4 3.5 4. 4.1 4.2 4.3 4.4 4.5 4.6 5. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6. 6.1 6.2 INTRODUCTION GENERAL PRINCIPLES AND PRECONDITIONS Principles Preconditions Supplementary areas BASIC PRINCIPLES IN RELATION TO CARE Upscaling Specialist medical care Organisation of care Differentiated care Design of the general hospital building guidelines BASIC QUALITY REQUIREMENTS Introduction Reachability Access Flexibility Spatial relationships Quality of the environment ARCHITECTURAL CONCEPTS Introduction Breitfuss model Double comb structure Arcade structure Cross structure Branched structure Linear structure Pavilion structure FINANCIAL ASPECTS Building development investment costs framework Practical application 1 2 2 2 2 4 4 4 4 8 9 11 11 11 11 12 13 14 15 15 16 17 19 20 22 24 26 29 29 30
General hospital building guidelines
1. INTRODUCTION These building guidelines concern the spatial facilities for a general hospital with basic quality requirements at the level of the hospital as a whole. Together with the basic quality requirements incorporated in the specific guidelines for specific functions of a hospital, they form the complete set of basic quality requirements with which building plans for new hospitals have to comply. The building guidelines were adopted by the Netherlands Board for Hospital Facilities (Bouwcollege) in a resolution passed on 7 October 2002, taking into account article 15a of the Hospital Provision Act (WZV), and approved by the Minister for Health, Welfare and Sports on 19 November 2002. As appendix 1.01, the guidelines form part of the Hospital Provision Act Building Standards Regulations. Please refer to the general section of the explanatory notes to the Netherlands Board for Hospital Facilities Regulations ‘General Hospital Building Standards’. In the Building guidelines Care Sector brochure, there is a description of the use of the guidelines and how they were developed. This brochure can be ordered from the Netherlands Board for Hospital Facilities. It can also be downloaded via the Board’s website: http//:www.bouwcollege.nl, where you will not only find these guidelines but also the specific guidelines for specific functions of a hospital, as well as other relevant publications. Chapter 2 deals with the general principles and preconditions when compiling and applying the building guidelines. Chapter 3 gives the basic principles related to care that form the foundation of the guidelines, based on evaluation and experience. Chapter 4 describes the basic quality requirements at the level of the hospital as a whole. Chapter 5 includes various architectural concepts with an explanation of how the basic quality requirements described in chapter 4 have been or will be incorporated in the building structure of a hospital. Chapter 6 deals with the spatial and financial conditions related to building a new hospital.
Building guidelines not only provide a description of the minimum space needs and functional requirements with which new care facilities have to comply. In the case of hospitals.). no basic quality requirements will be imposed with the exception of the kitchen facilities. such as the flexibility of the building structure or the quality of the built environment. various solutions are possible within specific frameworks. central sterile supply department). Scope Appendix 1 states for which hospital functions the basic quality requirements (will) apply. The basic principle in this respect is that only the patient-related functions of a hospital will be applicable for this. this may refer for example to minimum dimensions of patient rooms or spatial and technical requirements for operating theatres and laboratories. such as nursing. They also represent a reaction to developments in the healthcare sector in recent years and. Cost norms The guidelines have been flexibly designed so that. pharmacy. these frameworks are principally determined by maximum permissible investment costs. these “open standards” refer to aspects that particularly play a role at a level of the hospital as a whole. Examples include the Buildings Decree (relating to storey height.Nt. Chapter 6 describes how this investment cost framework is determined and how it is applied in practice. provide a picture of developments in the immediate future (chapter 3). Chapter 4 goes deeper into the above-mentioned basic quality requirements. The term “closed standards” refers to standards that are clearly quantifiable.General hospital building guidelines 2 GENERAL PRINCIPLES AND PRECONDITIONS 2. account was taken of regulations relating to environment legislation and regulations applicable to building in general. Building guidelines comprise two parts: basic quality requirements and cost norms.2 Preconditions When drawing up the guidelines.) and the Tobacco Act (that states that patients and staff must be able to function without hindrance caused by the use of tobacco products). safety and hygiene. the Working Conditions Act (relating to the use of sling hoists etc. given the basic quality requirements. usually general and technical supply facilities. During realization of these facilities. 2. With regard to the other. where possible.doc 2 . diagnostics and treatment and medical supporting facilities (laboratories.1 Principles Building guidelines Building guidelines are a tool to help prepare building initiatives in the healthcare sector. Basic quality requirements The Basic Quality Requirements describe the minimum requisite level of quality with which certain facilities or accommodation must comply in terms of functionality. “Open standards” mainly consist of generally endorsed guideline criteria that are difficult to quantify. It is this aspect that gives the standards their flexibility. whereby a distinction can be made between “closed” and “open standards”. They also form an evaluation framework for the architectural and functional assessment of building applications submitted by institutions. the Building Access Handbook (wheelchair access).3 Supplementary areas The above-mentioned guidelines are limited to facilities for functions that a care provider must or can provide. 2. it may be necessary to pay attention to other aspects that 0270-02. With respect to the building of WZV Hospital Provision Act facilities. As a rule. daylighting and ventilation regulations etc.
General hospital building guidelines are either related to or a consequence of the building activities. interim facilities or technical installations.Nt. Attention is paid to these aspects in other publications of the Netherlands Board for Hospital Facilities (http://www.nl). site size.bouwcollege. reference is made to them in this text. parking facilities. In instances where these publications may be of relevance.doc 3 . Examples of this include acquisition of land. 0270-02.
As a result of the developments in specialist medical care described in § 3. due to an increasing shift from inpatient to outpatient care and day treatment. 3. at both diagnostic and therapeutic levels and at a communication level. ICT has naturally made an important contribution to all of this. inpatient care is being 1 Netherlands Board for Hospital Facilities: Feasibility study on desired distribution of hospitals 7 November 2000 0270-02. From the mid-eighties. policy aimed at reducing the number of beds has led to amalgamation with new buildings as a survival strategy for the smaller hospitals. have created a need for interdisciplinary cooperation to grow. government policy has encouraged concentration. This upscaling led to a decline in the number of hospital organisations. BASIC PRINCIPLES IN RELATION TO CARE 3.Nt.2 Specialist medical care Developments in medical knowledge and science (applicable to healthcare) have led to extensive superspecialisation and sub-specialisation of physicians.doc 4 .3 Organisation of healthcare Until a few years ago. but not to an equivalent reduction 1 in the number of hospital locations . part-time work and the quality requirements of professional associations (that are often also applied by the Inspectorate) have led to larger partnerships.General hospital building guidelines 3. This referred to the premium related to the scale based on the assumption that large hospital in principle treats more complex patients. 3. Nor has medical technology stood still. Developments in concepts about hospital care and care organisation. Furthermore. developments in the field of the medical profession as such. as a result of which the need for intra-disciplinary cooperation has radically increased. quality requirements laid down by the professional associations and the introduction of expensive medical technology. Complex care and relatively expensive facilities such as general intensive care and cardiac care consequently tend to be concentrated. On the one hand. mergers took place on the basis of strategic considerations. lead to upscaling. virtually every specialisation had its own beds in the ward unit and diagnostic and treatment facilities in the outpatient unit. in anticipation of the announced introduction of market efficiency in the healthcare sector. The increasing juridification of the primary process also has an impact on the development of the quality requirements of the professional associations: patients have an increasing tendency to go to court.2 together with the fact that. due to the largely monodisciplinary approach to the patient’s care requirements. there has been a trend towards upscaling. due to having a more extensive range of functions. the hospital budget included a ‘merger premium’. This has led on the one hand to the necessary concentration of hospital care because it is only at a certain scale and production level that very expensive equipment can be efficiently used. for example increasing specialisation. Subspecialisation. From the mid-seventies. in which the wishes of patients are now playing an important role. organisation of healthcare was largely based on the perspective of the medical specialisations available in a hospital and the availability of diagnostic and treatment facilities. amalgamated hospital organisations often opt to keep locations open and divide functions differently over the locations. This is due to a number of causes. In order to maintain access to hospital care for the general public as far as possible and also for strategic marketing reasons (retention of market share). the scarcity of medical staff can also result in concentration. In addition. Furthermore. while on the other hand medical technology has also enabled medical specialists to function on a small-scale. On the other hand.1 Upscaling Since the nineteen seventies.
It is consequently also possible to combine the different planning models. based on the patient’s perspective. Some projects have opted to combine inpatient and outpatient activities within one care unit. metabolism & aging Theme 4: Acute care & musculoskeletal system Theme 5: Heart & vascular Theme 6: Growth. central kitchen. Theme 1: Brain & sensory organs Theme 2: Oncology Theme 3: Immune system. the care process around the patient is generally based on the principle of virtual multidisciplinary cooperation. general organ function investigation. a different emphasis may be placed on a number of aspects with regard to the organisation of the care. development and reproduction 0270-02. Planning on the basis of target-groups/clinical entities The basis of this model is clustering activities as far as possible around the treatment of the patient. Medical support includes imaging diagnostics. It is determined by means of protocols in what manner the different specialisations and medical supporting facilities are used in the treatment of the patient group. The care units concern the primary process. This trend has led to a reorientation regarding the way in which the demand for hospital care is offered. Although these display similarities. technical service and personnel facilities. Examples of care units/themes include ‘mother & child’. The choice and detailing of the organisation of the care is dependent on the situation and is largely determined by weighing up the interests of the patient and the care provider in relation to management (scale size). attention has been paid in recent years to a more integrated organisation of healthcare. ‘brain & sense organs’ and ‘heart & vascular’. This is based on grouping the different specialisations present in the hospital.Nt. The supporting units are focused on medical and general & technical support for the primary process. the pharmacy and the laboratories.General hospital building guidelines increasingly reserved for complex and difficult medical cases. it is shown that the functional and spatial planning of the above-mentioned units can be tackled in different ways. ‘oncology’. Other projects on the other hand have chosen a more traditional form of planning in which a greater distinction is advocated between inpatient and outpatient care and diagnostics. General & technical support mainly comprises facilities for management. whether or not certain specialisations are present. aimed at achieving a more or less comprehensive range of care for patients with similar clinical entities. Classification into care units/themes depends on the care profile of a hospital. In this situation. In broad terms the following categories may be distinguished. whereby a distinction is generally made according to care units and supporting units. The medical specialists work together around one patient group but do not have office visits at the same time at one location. This reorientation process concerns the logistic process in both the hospital organisations and the entire care chain. the scope of the existing specialisations and the hospital’s policy and profiling. patient care. These are forms of cooperation that are not recognisable in a physical sense.doc 5 . such as administration and provision of information. In practice. with the incorporation of medical supporting functions.
relationship with referrers and follow-up care and the building aspect. elective care and chronic care. A great deal of attention is paid to providing information and counselling to the patient. planability. This is in fact a well-equipped emergency department where mainly patients with severe trauma and injury are treated. Chronic care concerns care where a long-term relationship with the patient is required. urgent care. Elective care can usually be well planned. This type of care demands a strong personal contact in a relaxed. This time is used to gather information about the patient. weeks) between registration and an appointment. back problems. to prepare the treatment plan within the hospital or arrange any follow-up care. The acute care unit only deals with patients who are in a truly life-threatening situation.Nt. The underlying principle of this subdivision is the assumption that each patient flow basically differs from the other in terms of atmosphere. other parties concerned and the referrer. lung/asthmatic conditions and diabetics. it is necessary to determine what has to be achieved with each patient target-group (the objectives). In order to safeguard this planability. The urgent care unit deals with patients in cases where a few hours between registration at reception and treatment will not lead to problems. An observation unit forms part of the urgent care unit. patient associations and other parties involved about admission waiting-time. non-hospital-like atmosphere.General hospital building guidelines Source: Erasmus MC Rotterdam Planning on the basis of patient flows In this model a distinction is made between four patient flows: acute care. 0270-02. medical specialists.doc 6 . Agreements are made between general practitioners. With urgent care there is time between registration and carrying out diagnostic procedures and treatment. organisation. allocation of tasks and responsibility. The purpose of the urgent care unit is to relieve pressure on the adjacent acute care unit (emergency department) as far as possible. Examples of chronic care are patients with heart failure. A large proportion of the patients who are currently (wrongly) admitted to the emergency care unit will be treated in the urgent care unit. position of professionals. total treatment time. relatives. Elective care concerns care when there is a period of time (days.
6. • screening and diagnostic procedures. • aftercare in different forms. the knowledge/expertise centre where the professionals (in the broadest sense of the word) have a place to work and meet each other. This means that all information must be digitally available. the organisation and the facilities. 3. aimed at integrated planning of the care process – not only in the hospital but also outside. advice. the treatment centre where treatment is carried out. resulting in referral. the logistics centre from which support is given to the above-mentioned centres.Nt. resulting in six different centres: 1. treatment possibilities and treatment planning. 0270-02. appointment centre where consultations take place. 2. • treatment in different forms. as follows: • treatment from the general practitioner.General hospital building guidelines Source: Deventer Hospitals Planning on the basis of the care process This model is largely based on the stages through which a patient passes from the moment the patient arrives in the hospital until the moment he/she leaves it. 4.doc 7 . the centre for screening and diagnostics where investigations can be carried out. the nursing centre where nursing takes place. • care in different forms. 5. • appointment with the specialist(s) to discuss the diagnostic results. This model is based on the assumption that modern ICT techniques are applied. Grouped around these main processes are ICT. The basic principle is that professionals in the care chain must be able to consult all information independent of time and place. Six main processes may be distinguished here.
these forms are explained in further detail. but where no 24-hour care is provided (an independent treatment centre can fulfil this description). such as: • general practitioner centres in hospitals. specialist medical care that is not too complex. • the day hospital that provides general. 2 2 In the follow-up feasibility study on distribution of hospital care. Appendix 2 gives a number of examples regarding a possible constellation of hospital care spread over several different hospital locations within one single hospital organisation. part one (Netherlands Board for Hospital Facilities 14 January 2002).General hospital building guidelines Source: Orbis Sittard 3. • the university teaching hospital.4 Differentiated care The developments described above have led to a wide variety of forms of hospital care . • the specialised hospital that concentrates on certain sections of hospital care or certain targetgroups and where 24-hour care and/or day nursing is provided.doc 8 . as well as the Minister’s standpoint on this study (1 February 2002). 0270-02. • the external outpatient unit that provides outpatient care during office hours (an independent treatment centre can fulfil this description).Nt. The above-mentioned forms of hospital care occur in different organisation forms. New possibilities in the field of medical technology (minimal invasive therapy). • the general hospital where a distinction can be made between a basic hospital and a top clinical hospital/intervention centre. developments in ICT (telemedicine: monitoring and diagnostics at a distance using telecommunication technology) and further development of (transmural) care chains for specific patient groups are expected to result in new forms. varying from independently operating entities to a combination of facilities under one hospital organisation or in a cooperative organisational form.
clinical pathology). linen service and technical service. B. medical microbiology. C. maternity nursing (including delivery rooms). but are mainly focused on providing support and services in a general sense. the day nursing could also be placed under the main function group diagnostics & treatment. The special function main function group includes the spatial facilities for dialysis. However. nuclear medicine. • special functions (in so far as these are present). • diagnostics & treatment. general organ function investigations. general nursing. linen service. restaurant and technical service). general & technical support services. From the assessment experience of the Netherlands Board for Hospital Facilities. Based on examples from the consultancy experience of the Netherlands Board for Hospital Facilities. A. emergency unit and physiotherapy. The diagnostics & treatment main function group includes the following spatial facilities: outpatient appointment department. but merely forms a plan based on the different activities within a hospital. a rehabilitation day treatment unit or a radiotherapy unit. the table below shows (as an indicative average) what the share in percentage terms of the different 0270-02. Translated into spatial facilities. It should be added that this subdivision is not a blueprint for the way in which a hospital should be divided up. In the first place these are activities that concern the primary process.General hospital building guidelines 3. C. diagnostics and treatment). these different activities may be subdivided into three ‘blocks’: A. in other words the direct interaction between the patient and the care provider (nursing. In addition there are activities that have no direct relationship with the primary process. as well as facilities for management and training. in view of the nature of the care provided. This is particularly the case with the laboratories and pharmacy. administrative tasks.5 Design of the general hospital building guidelines The guidelines were drawn up on the basis of the different activities that take place in a hospital.Nt. Patient-related facilities where the patients themselves are present Three main function groups may be distinguished within this ‘block’ as follows: • nursing. the pharmacy and the laboratories (clinical chemistry. There is a trend towards outsourcing some of the facilities listed under B and C to third parties. outpatient treatment. Patient-related facilities where patients themselves are not present This ‘block’ includes the spatial facilities for central sterilising services. however. operation unit. or be situated in the close vicinity of the facilities for nursing.doc 9 . patient-related facilities where patients themselves are not present. General & technical support services This ‘block’ includes general and staff facilities (such as central kitchen. non-specific. imaging diagnostics. the day nursing unit appears in most cases to (still) form part of. B. paediatric nursing. patient-related facilities where the patients themselves are/may be present. kitchen facilities. The nursing main function group includes the spatial facilities for special care. geriatrics and day nursing.
General hospital building guidelines blocks is of the floor area on the basis of the usual function package of a general hospital.Nt.doc 10 . 3 (main) function group Share as percentage Standard package Block A: patient-related facilities (patient present) Block B: patient-related facilities (patient not present) Block C: general & technical (non-patient-related) services Total 65% 10% 25% 100% 3 Excluding special functions 0270-02. The examples concern initiatives as currently being developed within the framework of the “new style” hospital.
outside stairs (minimum width. assessed on the basis of transport frequency and the distance to the stop. the basic quality requirements are described at different levels: the location. The basic quality requirements formulated below at the level of the hospital as a whole and the basic quality requirements as incorporated in the specific guidelines form the complete set of basic quality requirements with which building plans for new hospitals have to comply. recreation. maximum height of kerbs). further basic quality requirements are formulated for the relevant hospital functions within accommodation (building structure). • Taxis should be able to come right up to the main entrance and the entrance to the outpatient unit.Nt. such as the National Building Decree and the Working Conditions Act. 4. conditions (including hygiene) and safety & security. Any additional or deviating basic quality requirements at both of these levels are described in the specific building guidelines. minimum free height. There are additional requirements for the less able.General hospital building guidelines 4 BASIC QUALITY REQUIREMENTS 4. A geographic/demographic concentration point is a municipality where the population level and level of amenities (schools.1. visitors and staff. maximum slope. These are more in the nature of “closed standards”. car or bicycle. maximum rise. such as the size of parking places and the height of parking meters. Where the conditions are concerned (mainly hygienic aspects and special climatic requirements). halfway and end platforms).3 Access • The site needs to be easily accessible by patients. continuous guiding lines must be present.doc 11 . please refer to the building guidelines for indoor environment and building-related installations of the Netherlands Board for Hospital Facilities. please refer to the regulations of third parties. 0270-02. Generally speaking. specifications apply to pavements/ footpaths (minimum width. in line with the provisions in § 2. For safety & security. In the specific building guidelines. public services) is such that a substantial proportion of the population in the catchment area of the hospital is more or less automatically orientated towards that municipality. rough and jointless) and lighting. the basic quality requirements are described at the level of the location(s) and the building structure situated there. installation.1. accommodation. retail trade. and take the form of “open standards” in line with the provisions in § 2. In these guidelines.2 Reachability • A general hospital should be easily reachable by public transport. this requirement is complied with if a general hospital is situated at one of the geographic/demographic concentration points in its catchment area. height and design of handrails).1 Introduction By analogy with the subdivision in the National Building Decree. material properties of paving surfaces (flat. In this connection. ramps (minimum width. and also by taxi. Obstacles should be indicated by warning paving. Regulations also apply to the measurements and layout of parking places. maximum slope and length. 4.
technology and policy when selecting the building structure. A characteristic feature of today’s hospital architecture is that account was taken of future changes and innovations in science. • Where main traffic areas are concerned. With a high level of flexibility. specifications apply to e.g. As a result of this.Nt. These entrances should be covered over and provided with good lighting. In the past. and the manoeuvre space in front of the lift door. minimum width. Where lifts are concerned.General hospital building guidelines • • The entrance to the emergency department and if necessary the main entrance should be accessible by ambulance. There are also specifications that apply to the entrance hall (sheltered situation. which have to comply with specifications concerning the maximum rise and the minimum tread and for halfway landings. The same applies to internal stairs.H. From the time that flexibility aspects started to play a role. the pavilion and Breitfuss models were among the most common used structures for hospitals. minimum dimensions. various architectural concepts have been developed in which flexibility is an important basic criterium. 4. A general hospital is a complex building with many rooms. layout or internal 4 flexibility and extension or external flexibility . In the case of revolving or carrousel doors. linear structure and variations on these structures. there must be an extra swing or sliding door provided. free access height. Utrecht 1991. Flexibility is important in the healthcare sector because we are concerned here with a structural process of change.doc 12 . R. The building structure should be simple to extend at different points and should be able to cope with internal displacement. Public entrances to a hospital building should comply with minimum dimensions and also be accessible by people with a physical handicap. please refer to the Building Access Handbook and the Guide to the Accessibility of Buildings in the Healthcare and Social Services Sectors. the presence and dimensions of rails along the walls and lighting. location of the doors. and Dekker K. these adaptations can be kept to a minimum. thresholds (maximum heights) and door handles. new structures appeared such as the comb structure. as follows: usage flexibility. Over the years. as a result of which the financial consequences and the hindrance to management – both in terms of building nuisance and spatial and organisational disintegration – remain within acceptable levels. There are four types of flexibility. spatial adaptation of buildings in this sector is inevitable.4 Flexibility The concept of flexibility refers to the degree to which a building is adaptable to changing space needs. the location of the operating elements and rails.: Flexibility as a building strategy for changing healthcare. the functional interpretation of which is highly varied. Disposal flexibility 4 Nicolaï. cross structure. lighting). 0270-02. For further specifications. Usage flexibility Usage flexibility concerns the possibility of changing the use made of a room/space without the need to renovate that room/space. specifications apply for example to cage dimensions and access height and width (depending on the type of lift). the direction in which doors open. • The main structural design of a hospital should possess a high degree of flexibility. disposal flexibility.
The possibilities for internal displacement are positively influenced by situating “hard” hospital functions (where specific conditions are laid down regarding equipment and installations) next to “soft” hospital functions (with standard conditions with respect to equipment and installations). These activities are not dependent on the organisational form of the hospital. it is assumed that after the extensions have been carried out. A primary proximity requirement is complied with if there is a direct link in a horizontal or vertical sense between two function groups or departments of a hospital. Consequently. laboratories. A supporting structure with concrete columns makes this possible because the internal fittings geared to the function can be removed without constructional consequences and be reconstructed once again. The hard hospital functions can in this way displace the soft hospital functions.General hospital building guidelines Disposal flexibility concerns the possibility of removing building elements without a detrimental effect on the cohesion of the building elements to be retained and with a minimum of hindrance. The nursing. One condition for these buffers is that the relevant functions should not place high technical demands on the building and that their location is not of major importance from an organisational point of view. diagnostic and treatment departments are concentrated in the main core of the hospital. Expansion possibilities are mainly programmed for functions where growth may be expected. On the other hand. These requirements are based on the different activities taking place in a hospital and are separate from the requirements that can be formulated on the basis of the organisation of the hospital.Nt. Internal flexibility The term internal flexibility refers to the possibility of interchanging hospital functions independent of the supporting structure. The pharmacy. thereby safeguarding future growth. The “soft” hospital functions act in fact as buffers. it is also possible to obtain a flexibly designed hospital. 4. An example of this is a building structure where functions that do not form part of the primary process are placed in separate building elements. A primary link is also necessary between the operating unit and the intensive care and obstetric units. In the design. This particularly concerns the outpatient 0270-02. It is worth recommending that the facilities to be used by outpatients should be situated so as to be easily reachable in relation to each other. On the one hand requirements are formulated that are derived from medical and logistic factors that are independent of the chosen organisational form of the hospital. A primary link of this kind is essential between on the one hand the emergency unit and on the other hand the operating unit. the functionality of the whole building will be guaranteed. storerooms and the kitchen are located in service buildings at a distance from the main core.doc 13 . the imaging diagnostics unit and the location where emergency treatment is given to heart patients. displacement of these functions should not form any great problem. Use can be made here of a lift with pre-selected control. the spatial relationships are determined by the organisation of the hospital. Proximity requirements as a consequence of logistic factors are based on the volume of patient. The proximity requirements arising from this aspect are subordinate to the primary proximity requirements based on medical factors. for which 3 possibilities have been outlined in chapter 3. When planning the hospital functions in relation to each other. It may be necessary to lay down proximity requirements for different parts of a hospital on the basis of medical or logistic arguments. Requirements based on medical arguments concern primary proximity requirements that are laid down because fast transport is essential in the interests of the patient. personnel or goods traffic between the different elements that form the hospital. For example: possible extensions will need to link up in a logical way to the internal traffic system and to the main infrastructure of the installations.5 Spatial relationships The demands placed on spatial relationships between the different components of a hospital in the architectural design are based on two elements. External flexibility The term external flexibility refers to the possibility of expanding the existing building structure.
is comfortable and increases autonomy. provides contact with the outside world: for example by making means of communication available (radio. 0270-02. It is the intention for the institutions themselves to be able to use this tool. It is worth recommending. the operating unit and the central sterilising services unit are usually located so as to make them easily reachable from each other. Requirements can also be laid down in connection with the volume of goods transport. The use of materials.Nt. tv. promotes the relationship with nursing staff: for example by the right location of the nursing station on a ward and the presence of an adequate nurse call system. telephone) and providing a clear view outside. for the sake of cohesion.6 Quality of the environment The quality of the built external and internal environment of hospitals not only has an impact on the wellbeing of the care providers. The Netherlands Board for Hospital Facilities is planning to develop a tool based on the concept of the English AEDET method that endeavours to objectify the assessment of the above-mentioned aspects. obscure corridors. but also on the healing process and behaviour of patients. Studies have shown that the well-being of patients and visitors is promoted by an environment that: • • • • • • • is easy to reach and where everything can be clearly found: for example a clearly recognisable main entrance and good signposting inside the building. attention is increasingly being focused on the role of the patient in healthcare. pays attention to relatives: for example facilities for visitors such as chairs in patient rooms. the hospital laboratory and the imaging diagnostics unit. This has been shown by the many studies that have been carried out in this field in recent years. is safe. 4. provides confidence and privacy. On the basis of the type of organisation chosen by the institution (see also chapter 3). secure and bright: for example by ensuring that sufficient daylight can penetrate. As a rule. colour and art play a role here. In addition. by using non-institutional furnishings and lighting and avoiding long. that the chosen organisational form should be expressed in the spatial structure.doc 14 . The results of these studies have led to increased attention being paid to the psychological impact of environmental aspects of healthcare institutions.General hospital building guidelines appointments desk. possibilities for rooming in (children’s ward) and resting facilities should the presence of relatives be necessary outside visiting hours. spatial requirements can be formulated between the different components of the organisational units and between these units themselves. including hospitals. facilities for organ function investigations. both visually (for example no undesirable views from the corridor) and acoustically (for example by use of sound absorbent materials and locating mainly quiet functions next to patient rooms). The relationship requirements arising from the organisational form are subordinate to the primary relationships formulated above.
Recently developed hospital designs are characterised on the one hand by more emphasis placed on the design. more neutrally designed hospital structures evolved. The examples show how concepts such as flexibility.doc 15 . On the other hand. the fact that these examples have been included here does not mean that a new hospital necessarily has to be designed on the basis of one of these models. Subsequent developments show a more internally-oriented design of the buildings. since hospitals have been increasingly built in an urban context due to land problems. through the use of covered streets and plazas. 0270-02.1 Introduction This chapter gives a few striking examples of hospitals that have either already been built or are in the process of development. fitting them into the urban environment has become an important concept. when flexibility became an important concept. In the eighties. Post-war hospital building in the early decades generated many hospitals with imposing.General hospital building guidelines 5 ARCHITECTURAL CONCEPTS 5.Nt. sometimes monumentally designed ward blocks. The following models will be dealt with: − the Breitfuss model − the double comb structure − the arcade model − the cross structure − the branched structure − the linear structure − the pavilion structure The building structure of a hospital has undergone a development that shows a decreasing dominance of the ward block. Examples are provided of each distinctive type of building. functional relationships and design were translated in the relevant period or are currently being translated into the building structure of the hospital. However. The treatment and outpatient departments and the flexibility and design of the main traffic areas have had an increasing impact on the main design of the hospital.
As a result of these limitations in the design. this model usually has a clearly recognisable main entrance. laboratories.2 Breitfuss model general A typical feature of the Breitfuss model is that a tall building block with nursing functions is placed above a flat building block with treatment and outpatient functions. imaging diagnostics. the stacking of the wards can mean that there is a considerable distance between the outpatient unit and the wards.General hospital building guidelines 5. flexibility Where flexibility is concerned.3). staff and visitors do have to make frequent use of the lifts. account has only been taken of the possibility of adaptation and expansion in relation to functions on the lowest floors. it is possible to create good spatial relationships with this type of building.doc 16 . The structure of the building shows a clear division between the static nursing units in the ward block and the dynamic departments on the lower two (or three) storeys. No possibilities for expansion or adaptation have usually been provided for in the ward block.).Nt. nursing unit. offers in principle sufficient possibilities for planning the facilities for care provided on the basis of patient flows or on the basis of the care process (see § 3. etc. The external appearance of the ward block is often of an imposing design due to its definitive status. The number of lifts is partly determined by the number of storeys of the ward block. it is more difficult with this type of building to comply with policy concerning the new style hospital that advocates a shift from inpatient to outpatient. The Breitfuss model is less suitable for planning on the basis of target-groups. functional relationships Since the lowrise structure contains all diagnostic and treatment functions. Where the medical staff is concerned. However. In the case of highrise with around 10 floors. The Breitfuss model. 0270-02. Due to its compact design. a considerable part of the ward block will be taken up by provisions for vertical traffic (lifts and (emergency) staircases). access In general it may be said that the Breitfuss model produces a compact building with relatively short walking distances. originally designed according to functional planning of the care provided (outpatient appointment unit.
an overall picture of the hospital is not visible.3 Double comb structure general The double comb structure is characterised by a traffic zone in the centre from which different building wings protrude like the teeth of a comb. this structure can lead to a sprawling design. the main entrance may be hidden between the teeth of the comb. the so-called “open ends”. In contrast with the Breitfuss model. 0270-02. In the case of large hospitals. It comprises many end walls.Nt. If located in the heart of the traffic zone. access Due to the many open ends. the external architecture gives the impression of being unfinished.000 m² 5. which make it simple to add extensions.doc 17 . The building structure is designed like a uniform grid.General hospital building guidelines example of Breitfuss model Location and name of institution date of completion number of beds gross floor area The Hague – Leyenburg Hospital 1971 750 beds 90. for example.
Antonius Hospital 1979 579 beds 61. flexibility The double comb structure was developed at a period when flexibility had become one of the most important design criteria. plus the pharmacy and the central sterile supply services unit. or wings with only nursing functions. From the point of view of size and technical requirements. Flexibility is guaranteed by extending the teeth of the comb or by extending the traffic structure by adding a new wing. intensive care on the first floor and the operating unit on the second floor. example of double comb structure location and name of institution date of completion number of beds gross floor area Nieuwegein – St.doc 18 .3 with regard to accommodating the care organisation. the teeth of the comb are geared to the functions to be housed there. the emergency department is located on the ground floor.General hospital building guidelines functional relationships Functions which have to comply with the same requirements are grouped in one wing. The double comb structure is in principle suitable for all three planning models described in § 3. The basis structure of the hospital remains unchanged after these extensions. For example. Practical experience has shown that stacking spatially related functions with specific requirements regarding installations can also be successfully done in one wing. Other designs may include all laboratories in one wing.000 m² 0270-02.Nt.
In Waterland Regional Hospital in Purmerend. flexibility In a similar way to the double comb structure. Maasland Hospital in Sittard.doc 19 .General hospital building guidelines 5. On the ground floor are the outpatient clinics. From the arcade. imaging diagnostics and the accommodation for management functions are situated near the main entrance. In the arcade on the ground floor are a number of public amenities such as shops and a restaurant. the traffic structure (arcade) can be extended while retaining the basic structure and new building elements can be added to it. the vertical means of access to the upper floors are clearly visible. and above those a technical floor.4 Arcade structure general The arcade hospital emerged as a new model in the early eighties and has been used a number of times in the Netherlands. In the centrally located areas of the building are the operating department. Parallel to the arcade on the ground floor and the first floor will come the outpatient department facilities. will also be built according to the arcade structure. at right angles to the arcade.3 with regard to accommodating the care organisation. The main entrance at one end of the arcade is easily recognisable. Above these. A section of the building for treatment functions is planned in the heart of the complex. on the top three floors. will be the nursing wards. The top two storeys house the nursing wards. The outpatient departments. the building elements of the hospital are linked with each other by a glass-covered arcade for main traffic. Located on both sides of this arcade. laboratories and physiotherapy. Flevo Hospital is also based on an arcade model. functional relationships It is evident from the hospitals built in accordance with this model that organisation can take place in various different ways. currently at the design stage. In Almere. access The high arcade is a clear structuring element. In this model.Nt. on the first floor the operating department and the laboratories. The building elements linked 0270-02. At the end of the arcade are two building elements containing the nursing wards. are the rooms or internal access routes that look out onto the arcade. but in this instance the functions have been placed behind each other in different parts of the building. the functions are located above each other. The arcade structure is in principle suitable for all three planning models described in § 3. on several floors. the emergency department.
doc 20 . example of arcade structure location and name of institution date of completion number of beds gross floor area Almere – Flevo Hospital 1991 213 beds 19.General hospital building guidelines to the arcade usually have open ends on the other side that make it simple to add extensions in the future.000 m² 5. The covered hall is the centre of the building and contains the central facilities.Nt. 0270-02. two building blocks each in the form of a cross have been linked to each other so as to create a large covered hall between the two building blocks.5 Cross structure general In the case of this model.
From the two intersections. This plaza is the heart of the structure and contains the central facilities. a walkway diagonally crosses the central hall at a first floor level. Virtually all the nursing wards are housed on the top four storeys of this hospital. The vertical access points in the cross-shaped building blocks are clearly visible from the plaza.Nt.General hospital building guidelines access The main entrance is located in on corner of the covered hall. Between the upper and lower level is a technical floor.000 m² 0270-02. functional relationships The best-known hospital based on this model is the Rijnstate Hospital in Arnhem. thereby reducing walking distances. This structure lends itself well to the development of a relatively large hospital within a compact design. flexibility The open ends of the cross-shaped building sections can be extended while retaining the basic structure. The cross structure is in principle suitable for all three planning models described in § 3. example of cross structure location and name of institution date of completion number of beds gross floor area Arnhem – Rijnstate Hospital 1994 750 beds 82. The outpatient departments and treatment & diagnostics units are located on the lower level.3 with regard to accommodating the care organisation.doc 21 .
but this is located on the same side of the square as the main entrance.3 with regard to accommodating the care organisation. This concerns the X-ray and operating departments. The Antonius Hospital built in Sneek is also characterised by lowrise building. This means that all the wards have a pleasant view over the green surroundings. pharmacy and laboratories. Most nursing wards are located in the branches leading off the square. flexibility Due to the existence of many open ends. a square central hall forms the heart of the building. The following observations may be made regarding flexibility in the Antonius Hospital.doc 22 . The situation and size of the site made it possible to build a relatively lowrise hospital. In this hospital. a look will be taken at two completed hospitals where the most characteristic element of the structure is formed by the number of branches and open ends. Supporting outside walls have been used for patient accommodation. functional relationships The Canisius-Wilhelmina Hospital in Nijmegen was built according to this design. The different function groups have been housed in separate building elements with a construction and raster size geared to the function group. access The main entrance is directly linked to the central hall. Since each 0270-02. separate buildings elements were developed per main function. this hospital is relatively lowrise. The outpatient departments have their own entrance. In both of these hospitals. A branched structure is in principle suitable for all three planning models described in § 3. The operating department and intensive care are situated on the top floor. while diagnostic. The services building is located separately so that this function can respond to future developments. a branched structure possesses by definition sufficient external flexibility.General hospital building guidelines 5. treatment and service functions have a skeleton structure. From this central hall the patients and visitors can gain access to the most important departments of the hospital. With an average of 3 storeys. The central hall is the centre of the structure and contains amenities such as boutiques and a restaurant.6 Branched structure general Under the heading branched structure. Functions which require a higher building height have been located on the top floor. The main stairwells and the lifts are easily accessible from the central hall. This concerns the Canisius Wilhelmina Hospital in Nijmegen completed in 1992 and the Antonius Hospital in Sneek completed in 1994.Nt. physiotherapy.
all multi-bed rooms can be partitioned into maximum one-bed rooms.General hospital building guidelines main function is located at an open end.Nt. the possibility of expansion is guaranteed.doc 23 . example of branched structure location and name of institution date of completion number of beds gross floor area Sneek – Antonius Hospital 1992 270 beds 29.000 m² 0270-02. All beds in the multibed rooms are of equal quality due to the fact that the beds are located by a window. In addition.
000 m² 5. Stairwells and cable and piping shafts have been incorporated in a rational design in the central zone. The depth of the block is approximately 22 metres and is designed for the application of a double corridor.7 Linear structure general For the draft plan for Vlietland Hospital in Schiedam.doc 24 . 0270-02.General hospital building guidelines example of branched structure location and name of institution date of completion number of beds gross floor area Nijmegen – Canisius-Wilhelmina Hospital 1992 638 beds 63.Nt. a design has been developed consisting of a single linear block that can accommodate all hospital functions in accordance with their inter-relationships.
additional glass connection corridors have been designed between departments located opposite each other. outpatient departments are located next to nursing wards. Internal flexibility is good. In the case of future bed reductions. This design is fully in accordance with policy on new style hospitals where a shift from inpatient to outpatient is advocated. The linear structure is in principle suitable for all three planning models described in § 3.3 with regard to accommodating the care organisation. wards can easily be converted into outpatient clinic space. In this way acceptable walking distances have been achieved. due for instance to the rational uniform design which makes it possible to interchange functions. function relationships The dimensions of the linear building have been geared to house both outpatient clinics and nursing wards.doc 25 . An entrance is located on both sides and opens into a high glass hall that is wedged between the linear building block. On different floors. The different lifts and stairwells can be reached from the central hall. In places where a short link is required for functional purposes.Nt. 0270-02. flexibility There are limitations regarding the external flexibility of the design of Vlietland Hospital on account of the fact that it only has two open ends and due to the size of the site.General hospital building guidelines access The linear block forming the hospital is designed with a number of kinks so that the overall shape resembles a hairpin.
0270-02.000 m² 5. This method was abandoned after the war.Nt. themes or type of care. however. Today. A cluster of categorial hospitals was built on the site. some designs for large hospitals are returning to the pavilion structure and opting for a plan according to clinical entities.doc 26 .8 Pavilion structure general During the pre-war years. larger hospitals were built according to the pavilion structure. A characteristic feature of the pavilion structure is that the spatial facilities that form part of the chosen plan are grouped together. An example of this is the design for the Isala Clinics in Zwolle.General hospital building guidelines example of linear structure location and name of institution date of completion number of beds gross floor area Schiedam – Vlietland Hospital 2006 (planned) 453 beds 48.
The building blocks will be built on three sides of the existing complex. facilities for outpatients decrease as inpatient facilities increase. Changes in activities and space between the functional units as a result of developments in the care sector will be difficult to achieve in the future without a change in the basic organisation principles. Situated beneath the new building blocks is a parking garage from which all four blocks can be reached. In addition. Each block has an atrium. varying from four to six storeys.General hospital building guidelines access The design of the new building for the Isala Clinics comprises four blocks. organised per block according to clinical entity. functional relationships The new building will house virtually all patient-related functions. flexibility A design based on planning according to clinical entity in one or more building elements has a negative effect on flexibility.doc 27 . The pavilion structure is particularly suitable for a plan based on care according to target-groups/clinical entities. 0270-02. This design has several different entrances as a result of which extra measures will be necessary from the point of view of security and surveillance. External flexibility does exist.Nt. Account has also been taken of constructing an extra floor on top of the different building elements. As you move higher up the building. since in this design a number of building elements can be extended at the ends. however. passing into a central hall into which opens an extensive system of corridors providing access to all the building elements. the main entrance is located between two blocks.
General hospital building guidelines example of pavilion structure location and name of institution date of completion number of beds gross floor area Zwolle – Isala Clinics last section 2011 (planned) 911 beds 126.Nt.doc 28 .000 m² 0270-02.
outpatient: 104 m² per 1.000 adherent inhabitants. The investment costs framework for a new building intended to completely replace a hospital will subsequently be determined by multiplying the total gross floor area (normal + specific functions) by the building price per m² for a hospital as incorporated in the Annual Note on Building Costs of the 5 Netherlands Board for Hospital Facilities . and in addition to the inpatient flow also allow the outpatient flow to be a determining factor for calculation of the normative floor area of a hospital. In the new calculation method. the Netherlands Board for Hospital Facilities advised the Minister in an alert report to drop the bed parameter and change to an ‘adherent inhabitant’ parameter. The normative floor areas per patient flow calculated according to the method together form the total normative permissible floor area for the normal function package of a general hospital. on the basis of which the normative floor area is calculated. This parameter. On 26 November 2001. The investment costs framework for a hospital is determined by two quantities: the normative floor area and the building costs per m². the floor area calculation based on the bed parameter continues to apply (see also the aforementioned alert report ). has been linked to the bed parameter. which is exclusively based on the inpatient flow. the cost of the land and the starting costs.000 adherent inhabitants). The investment costs comprise three components: the direct and building-related costs. takes insufficient account however of the reduced use of beds in hospitals as a result of a shift from inpatient care to outpatient care and day nursing. 5 As long as the Minister has not yet agreed to the new calculation method given in the Alert Report “Method of calculating normative floor area. alternative to the bed parameter” (Nov. leading to the future adherency per patient flow of the hospital. the general hospital also has special functions for which the space requirements can be determined with the help of supplementary floor area indicators adopted by the Netherlands Board for Hospital Facilities on 7 October 1996 (recommendation concerning capacity parameters article 18 Hospital Provision Act) and on 18 November 1996 (recommendation concerning other PM items relating to space requirements standardisation).General hospital building guidelines 6 FINANCIAL ASPECTS 6.1 Investment costs framework for new buildings This chapter shows how the maximum investment costs can be determined on the basis of the currently applicable Annual Note on Building Costs. this future adherency per patient flow will be multiplied by a normative floor area per patient flow (inpatient: 162 m² per 1.Nt. 2001). a market share will be determined per patient flow (inpatient and outpatient adherency) that will be projected on the future population in 2010. Until now the applicable floor area standard figure for hospitals. In addition. 0270-02. Indicators have been included in the Building Standards Regulations for both quantities. Inventory costs for a general hospital are not assessed within the framework of the Hospital Provision Act (WZV). In some cases.doc 29 .
inventory and starting costs Please refer to the provisions in the Annual Note on Building Costs for land. in line with the CTG (National Health Tariffs Authority) policy regulation on capital costs when outsourcing. Occasionally. a hospital organisation can opt to create less floor area than would be permitted according to the calculation method norms and to use the investment costs that hereby become free to finance additional investments in ICT for example. You then take a look at the size of the internal layout losses of the existing hospital location.940 m² € 2.2 Practical application Given the investment costs framework.000 m² 43. The mechanism described above is applicable one to one in cases of new building development that is intended to completely replace a hospital organisation.000 inhab. on the basis of which it can be determined how many m² of new building or renovation will be provided for. exclusive land.212. such as large-scale concentrated building adjoining an existing hospital location that has to be renovated.doc 30 . In situations where this is not the case. a hospital organisation can create more floor area within the framework for investment costs than is permitted within the calculation method norms.000 inhab. 2001.000 inhabitants Standard package Inpatient adherency 150. inventory and starting costs.€ 97.5). 0270-02. Gross floor area Inpatient 162 m²/1. Outpatient adherency 160. determination of the investment costs framework takes place as follows. a hospital organisation has the freedom to develop the required architectural care infrastructure as it sees fit. Conversely. convalescent unit). an investment costs framework is determined in the table below on the basis of a fictitious example.1. It should be added here that if the reduction in the floor area is a result of outsourcing specific services (see § 3.640 m² 40. Total PM items Total floor area Building price per m² *) Total investment costs framework 24.Nt. In the first instance. 6.000 inhabitants Total *) Source: Annual Note on Building Costs 2002. the standard permissible floor area of a hospital organisation is calculated on the basis of the method described in § 6. price level 1 Jan.General hospital building guidelines By way of illustration. the framework for investment costs will be reduced accordingly. while the investment costs for the renovation depend on the physical-functional and technical installation state of the building at the existing hospital location as well as the projected functions.2 mln Outpatient 104 m²/1. The size of the new building is multiplied by the building cost per m² for a hospital as stated in the Annual Note on Building Costs.940 m² 3. for example in a multi-location model or in order to facilitate transmural cooperation with other care facilities (eg general practitioner centre. VAT.300 m² 16. incl.
These differentiated cost norms can be used as a basic criterium in situations where a hospital organisation is only intending to put up a new building for a specific hospital function.General hospital building guidelines The building cost per m² stated in the Annual Note on Building Costs concerns an average price per m² that includes both expensive m² (for example for the operating department. laboratories) as well as cheap m² (for example for office-type facilities). In the specific standards with basic quality requirements there are differentiated cost norms for the relevant functions. 0270-02.doc 31 .Nt.
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