Healthcare facilities are some of the most complex building types, involving many layers of design and requiring a wide range of skills in order to create a building environment that in itself supports the healing process.
Today’s architects recognise that a buildings can either contribute to or hamper the welfare and recovery of patients, and are therefore trying to create more healing environments than the typically deep plan and soulless hospitals of the past’.
More and more research is becoming available around the world to show that patients recover faster and stay in hospitals for shorter periods of time if the right kind of healing environment is created.
“Healthcare facilities are highly functional buildings which simply enable doctors, nurses and other healthcare professionals to care for sick people,” says Matt Audinwood, healthcare manager at Ruben Reddy Architects, who specialise in healthcare design.
He explains that the ergonomics of a hospital is really what drives the initial design concept –the building itself must be an effective interface between the medical profession and the patient, but it must also accommodate all of the healthcare technology, equipment and solutions that go with it.
Put method to the madness
Because of the complicated nature of a large hospital facility, a large number of different disciplines are involved in the design, documentation and construction. Audinwood therefore suggests that an “opportunistic process-driven approach” is required.
“Designing a large hospital is a very involved process which first requires a deep understanding of the client’s needs. As we develop that understanding, we simultaneously build up a schedule of accommodation which documents how big each space is, how many rooms there are, what their primary function is and what adjacencies are required between each room or group of rooms – until we have a complete theoretical picture of what is required – and this becomes the brief,” he explains.
A basic formula
Although some clients may have very specific or special requirements for their particular facility, Audinwood notes that there is a common formula for most types hospitals which specialist healthcare architects understand.
For example, the Admissions, Pharmacy, Casualties and X-ray departments of most hospitals tend to be grouped together, close to the main hospital entrance so that patients and visitors can be admitted or directed efficiently without having to go deep into the building where more critical or sensitive functions like operating theatres and intensive care wards are located. Support services like the kitchen, laundry & waste management must also be situated at ground level, but generally at the back of the building, so that everything functions smoothly without conflicting or cross-circulation problems interrupting the operations of the hospital.
“Once the basic functionality and key adjacencies of the hospital planning has been resolved and working well, you can start putting the 3D puzzle together into a firm, three dimensional concept design, which, once approved by the client, is developed into a preliminary design and then into the detailed hospital design and construction documentation,” explains Audinwood.
Layers of complexity
“As the design develops over time, more and more layers of information and specialist input are overlaid and integrated in to the design including the structure, mechanical ventilation, lighting, wet services, medical equipment, IT, interior finishes and more – until a fully coordinated design is achieved. The completed hospital design will have incorporated input not only from architect, client, user, and facility manager but also from the structural, civil, mechanical and electrical engineers, acoustic and cost consultants, landscape designer, specialist equipment providers, as well as the health and safety consultant and interior designer.”
In South Africa, relatively tight budgets for healthcare facilities means that architects must “box clever” by looking carefully for ways to create good, appropriate architecture out of this challenging and often conflicting set of requirements. According to Audinwood, “good healthcare architecture is not just about the shape of the building and the materials used, but more holistically, how the entire design process is shaped to optimise every opportunity to add value to the final product, including passive environmental design, sustainability, functionality, economy, and above all to build a structure which is uplifting, healing and of this time and place”.
“In my opinion, a new hospital must appear clean, modern, efficient, welcoming and create a healing environment in every sense of the word,” he says. “At Ruben Reddy Architects, we feel that the most appropriate hospital interior is visually clear, uncluttered, clean, easily maintainable, and we therefore tend to think of the interior as a neutral canvas where colour is applied through finishes such as curtains, paint, artwork, lighting, textures, to create an uplifting, healing environment.”
From a sustainability point of view, Audinwood advises architects to stay mindful of our responsibility to minimise every building’s total carbon footprint of new buildings, to design with a whole lifecycle attitude and to be practical and realistic when specifying to minimise building maintenance. For example, movement sensors, photovoltaic cells and modern heat pumps can significantly reduce electrical loads, while greywater systems, well specified taps and showerheads can save natural resources.
Down to details
When it comes to the specifics, Dirk du Preez, project architect at Graceland Architects, a firm that designs and implements healthcare facilities across Africa, points out that salutogenic design and evidence-based design (EBD) are two main fields of interest, both of which are backed by extensive research with regards to their effects on patient recovery.
Salutogenic design is based on the broader concept of salutogenesis which was developed by a professor of medical sociology, Aaron Antonovsky, and describes an approach that is focused rather on wellness factors, elements that promote overall human health and well-being, than on the risk factors, finding what causes disease or treating an illness.
Furthermore, EBD constitutes a multitude of design processes that have been proven to have the biggest positive effect on most patient groups, and this is what architects work towards. “We don’t only design for the patients, we also design for the staff who work there, because the better they do their jobs, the bigger the benefit for the patients,” adds Du Preez.
Bring the outside in
Natural light is one of the aspects that have the biggest influence on a person’s health, while an outside view or nature inside the building, even putting nature scenes against the walls, has a calming effect. “This is very difficult to design for since it influences the building’s form and can be expensive, but our goal is to incorporate courtyards and gardens as much as possible,” says Du Preez. Another way is to use natural materials and patterns such as wood and stone.
Privacy and support
According to Du Preez, as part of patient experience, privacy is key. The biggest push currently is to have less beds in a ward, with the ideal being single rooms. Provision should also be made for family support in terms of comfortable and calm waiting areas, as well as benches or chairs around the beds.
In addition to installing acoustic ceiling tiles in private areas and theatres, another way of blocking noise and aiding in privacy is to have the walls extend above the ceiling height. This prevents sound from travelling over walls and through the ceilings.
Preventing germs from spreading
Frequent handwashing remains one of the most effective ways to prevent the spreading of germs, especially those transferred through direct touch. Therefore providing enough basins, conveniently positioned throughout the hospital, is a vital consideration in healthcare design.
Homogeneous materials, which are waterproof and easy to clean, are also hygienic choices.
Calm and comfort
To make the space attractive and non-threatening, Du Preez advises using calm and neutral colours in the design. “In my opinion, the floors should be a darker colour than the walls to separate the horizontal plane from the vertical plane and make it easier for people to orientate themselves when they are unsteady, nauseous, partially sighted or suffering from vertigo,” he explains.
“Also, while people typically see shining floors as a sign of cleanliness, it is actually quite distressing to people is sometimes misinterpreted as standing water and a fall risk that can cause a feeling of unease and distress. So shiny floors are something I try to avoid,” Du Preez says.
The big picture
Ultimately, healthcare architecture is not just about designing another building; it is about having a clear understanding of the process, functionality, technology and needs of everyone who use the facility, and creating an environment where all these needs are addressed in an efficient and integrated way.
Pam Bate, former WAN Awards Healthcare judge and partner at Hopkins Architecture in the United Kingdom, hits the nail on the head with her comment: “People in hospital would like to believe that the facility where they are being treated has the best doctors and the most up-to-date and innovative equipment to ensure that they and their loved ones are being cared for in the best possible environment.”
Full thanks and acknowledgement are given to Ruben Reddy Architects, Graceland Architects and World Architecture News for the information given to write this article.
Project highlight: Nelson Mandela Children’s Hospital (NMCH)
According to Audinwood, the success of this building, which is nearing completion, lies in its clearly legible and shallow plan design that optimises natural light which is known to be a great healer. Strategically placed and visually vibrant play areas also bring joy and happiness which in itself speeds up the healing process of children.
“I think this kind of solution is particularly suitable for children – keeping it light, bright and cheerful. The NMCH is a good example of modern hospital planning which has now gone full circle back to some of the simple principles recognised by Florence Nightingale in the turn of the last century,” he says.
Project highlight: Paardevlei Private Hospital
The way Paardevlei Private Hospital had to be orientated was determined by the size and shape of the site and its urban context. This resulted in long East and West facing facades which posed the challenge of controlling heat gain. “To overcome this, we designed fixed aluminium sun shading in an inverted L-format to shade tall, narrow windows very effectively from the harshest sun – a functionally-driven design which I think lifts the architecture and makes the building more interesting and attractive,” says Audinwood.
“The inpatient ward planning at Paardevlei is also very successful because the extensive use of patterned glass shopfronts along one side of the wide central corridor which gives the overall impression of natural lights and a sense of nature within the ward.”
Project highlight: 2 Military Hospital in Wynberg
The W2MH Project has been a particularly challenging project for Audinwood’s team at Ruben Reddy Architects because it involved the complete re-fit of the entire 1974 built hospital, which had to remain fully operational throughout the project. Consequently, a lot of temporary enabling works had been required to allow one floor at a time to be decanted so that the building work could progress in phases.
Despite the great many challenges and extreme complexity of this project, Audinwood says that “a fresh, modern and efficient look has been created and a modern state of the art hospital is evolving, which will not only increases SAMHS capacity to care for military patients but also raises the bar of public sector hospital projects around the country.
Project highlight: Mediclinic Gariep Hospital
In designing Mediclinic Gariep, Graceland Architects focused on incorporating gardens in the design. With full support from the hospital management, all the wards and waiting areas were formed around courtyards.
“Situated in the hot and dry Northern Cape, it was quite a challenge to establish gardens there, so a landscape architect was involved from an early stage,” explains Du Preez. “She selected plants from the region and has been appointed on an ongoing basis to maintain the gardens. Feedback from patients and staff is that these gardens create a very calm and peaceful atmosphere.”
Project highlight: Mediclinic Midstream
With a focus on providing views over nature, the Mediclinic Midstream hospital consists of different blocks that are positioned to each have a view over the Highveld. Graceland Architects designed the wards to face the downhill part of the site so that patients can look out over the horizon. The many windows mean that almost every bed has a view, most of them overlooking the Highveld.
Critical features of EBD:
• Natural light.
• Single bed patient rooms.
• Regular hand washing.
• View over nature.
• Scenes of nature on the walls.
• Indoor plants.
• Noise reduction.
• Calming colours.
• Natural materials or patterns.
• Contrast between floors and walls.
• Space for family support.