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The evolution of hospital design

by Ofentse Sefolo
The evolution of hospital design

Floors in Africa magazine recently spoke to Chad Brandon Paul, Healthcare Architect at Clinix Group, to discuss the pitfalls around flooring specifications for healthcare facilities, the evolution of healthcare design, how healthcare will change going forward and how the design of hospitals may change as a result of the pandemic. Here are his expert insights:

1. What are the major design issues around hospital and healthcare facility design and specification?
Hospitals are complex structures that represent the perfect marriage of form and function, of societal need and cultural nuance. These multifaceted characteristics of healthcare are what makes it complex in nature.

The clinical focus of healthcare design centres around the logical order that governs the sterile environment through a set of privacy thresholds organised through and influenced by infection control protocols. Although specialist healthcare designers are well versed in the knowledge of the clinical environment, we are far removed from the day-to-day operations. This means that we respond to spatial adherence but lack understanding of realistic ergonomic functionality. The medical sphere is also evolving and advancing exponentially and often architects and designers don’t take these medical advancements into account.

One of the primary issues with healthcare design is thus the lack of engagement with clinicians on all levels. How often do we have a nurse around the table when we design a nurse’s station in a ward? By opening the engagement up to the end users, we begin to create a dialogue that yields vastly new ideas and concepts on how to interact with the clinical environment and functionally to soften the sterility of clinical spaces for the patient.

Whilst we see that healthcare is evolving into a more patient-orientated experience, we can only really translate this successfully through our designs when we actively collaborate with clinicians that are active every day on the ground.

The healthcare sphere, being one that is ever-evolving, is a living organism that requires constant attention. We as healthcare designers need to realise that we cannot remain stagnant and complacent in our knowledge. We need to continuously research and navigate through the advancements in the industry.

Because of the fast-paced nature and budgetary constraints of healthcare projects, many designers tend to stick to the finishes and specifications that they know well. In an effort to keep up with the ever-evolving healthcare industry, we need to take the time to engage suppliers, both existing and new, and educate ourselves on the new finishing specifications that the market has to offer. Suppliers are the ones we need to engage with constantly when trying to find innovative ways to put clinical finishing specifications together. Through these discussions, we are able to express our design needs, our clinical concerns and raise technical discussions.

2. What are the pitfalls around healthcare flooring specification and installation?
It is important to remember from the onset that a healthcare environment is different to any other environment in that once the contractor reaches practical completion and patients have been admitted, it is very challenging to do any reworks. It is therefore important to get technical installation methodologies correct from the beginning of the project.

South African healthcare facilities also tend to be utilised for longer periods than their actual intended lifespans and designers need to realise that when specifying floors finishes. It is generally recommended that a healthcare space be upgraded every five to seven years, but locally, we tend to push that out to ten or even fifteen years. The cost of installing good quality flooring is much higher, but it lasts much longer.

In an effort to adhere to sterile requirements, we try to encourage the use of seamless floor and wall finishes with as few joints and seams as possible. The consequence however, can be a lack of innovation, as we quickly turn to the limited selection and knowledge that the South African market offers instead of stretching our creative thought. I am pleased to say that this is changing as I am seeing designers marry warmer and more natural tones with the correct flooring compliance specification through the implementation of accent areas, colours and textures.

Whilst sheet vinyl tends to be the most clinically compliant floor specification, it does have its disadvantages in terms of joint issues, upstand cap-strips that aren’t installed correctly and bubbling because of insufficient prep work. When we are busy with a new project, we insist on inviting the vinyl supplier to site to give them the opportunity to brief the installer on how the product is meant to be installed. We also insist that the contractor prepares a sample area which should include an example of the upstand and capping strip detail, so that the supplier can engage and advise on the quality thereof, and sign it off.

Most suppliers also recommend a self-levelling screed when installing vinyl flooring, but often contractors try to convince their clients that it is not necessary. Through personal experience, I have found that although it is costly, it is necessary. Some of the more notable vinyl suppliers are now insisting on a self-levelling screed as part of their method statement to ensure that their own liability is covered.

Transition thresholds between two varying floor finishes also tend to be a nightmare in healthcare facilities and it is at this weak spot where the finishes most often fail. Again, we would prefer to have smooth joints with little or no transition strips, but unfortunately, a transition strip becomes important to protect and maintain the longevity of the product and application.

Designers need to remember that over-and-above the standard pedestrian traffic on a floor, there are beds, trolleys, equipment and furniture constantly being moved over surfaces – and often at high speeds. In saying this, we need to research the appropriate applications and products that specifically cater for such traffic.

3. How has healthcare design evolved in recent years?
The design of healthcare facilities is seemingly moving away from the conventional doctrine of what hospitals are perceived to be to a more unrestrained engagement on how spaces can benefit not only the physical well-being of patients, but also the psychological welfare of all users.

Designers have begun to shift their focus from pure clinical adherence to more people-centric design. However, challenging the norm is only possible when designers have a comprehensive understanding of the clinical environment, the significance thereof, and the confidence in their knowledge to effectively design of people-centric spaces.

Globally, hospital spatial and aesthetic planning is also slowly moving away from pure sterile adherence to the more holistic creation of spaces that are empathetic to the patient’s and staff, needs.

By creating patient-centric spaces rather than focusing only on clinical considerations, both hospital operators and the users have the opportunity to reengage their perceptions of what healthcare is about.

Historically, patients tend to choose to be admitted to the most conveniently situated hospital. Now I think consideration is also being given to the most modern and most comfortable hospitals.
Through patient survey research, it is clear that patients and visitors understand that they can receive a very similar clinical experience from most hospitals, but what they can’t get everywhere is a good service experience topped with a new and exciting spatial environment.

The finishes being used in hospitals are also beginning to evolve somewhat, where palettes seen are becoming warmer and more reminiscent of hospitality specifications compared to the sparse white clinical monotony of facilities gone by.

Patients have realised that they should be benefiting more from their insurance by means of a better quality healthcare experience, and that realisation puts pressure on private facilities to improve their spaces and service offering. Floor finishes, joinery, wall treatments and furniture specifications are evolving to meet the higher expectations that insured patients are putting on private healthcare facilities.

It’s an interesting competition to see who is pushing the boundary on patient experience; and consequently, an exciting one for designers in the healthcare sphere. The evolution gives us an exciting opportunity to add value to what was once only seen as pure functional design to one that marries function with holistic spatial consideration.

4. What trends do you see for healthcare going forward?
The healthcare industry will continue to be transformed by new innovations with substantial moves in technological advancement benefitting both patients and clinicians. But more subtle changes will affect designers, as we will be encouraged to use data-driven information to create smarter and more efficient healthcare environments and to translate the users’ needs more clearly into effective spatial planning.
The trends we see will rely heavily on the user experience. As healthcare requirements evolve, the clinical environment will most likely be translated into a more outpatient-based setting, with formal hospitals becoming more and more specialised, providing care for only chronically ill patients. This means that if you are admitted to a hospital, you will most likely be admitted for something serious, and for a longer time.

The designer will need to react proactively to this by creating an environment that encourages a comfortable longer stay for the patient and, possibly, their families. Subsequently, elements of retail and hospitality design will continue to influence healthcare design, and engaging these elements will be key in creating clinical environments that are user-friendly. Physical environments will become more inclusive in the 2020s, employing holistic design to address patient needs across multiple health spectrums, including mental and behavioural health.

Healthcare will also seek to actively promote holistic well-being, with medical aids already partnering with their members and incentivising healthier lifestyles and greater overall wellbeing. This trend is going to translate into hospitals becoming more health-orientated and not necessarily places reserved only to service sick people. Already, healthcare systems are also being extended to outpatient and telemedicine systems that offer care and engagement through virtual platforms.

5. Any comments on healthcare architecture in a pandemic world?
The South African healthcare environment has contextually and historically been good at reacting to health-related pandemics and epidemics, but we have never had to adapt so quickly. The COVID-19 pandemic has provided the South African – and international – healthcare community with the prime opportunity for some introspection and revaluation of their progress, or lack thereof, in healthcare advancements over the past few years.

Aside from the grave disparity between public and private healthcare in South Africa being explicitly exposed through the COVID pandemic, we have also exposed certain liabilities within the healthcare design sphere that could arguably have been better planned or better executed had we been given any form of pre-warning that such a pandemic was imminent.

Scientists from Stanford University warn that as people continue to transform natural habitats into agricultural land, viruses that jump from animals to people will become more common. So in order to reinforce our competencies as designers, we not only need to take cognisance of the severity of the current situation, we also need to future-proof our facilities for what may come.

In our efforts to prepare for the impact of the virus, our shortcomings have been noticeably highlighted and it is clear that there is still a great need for both basic and specialised healthcare infrastructure in South Africa in both the public and private sectors. Our bed-to-population ratio is one of the most disproportional in the developing world. So on top of the deficit of appropriate healthcare facilities, we also need to creatively rethink how we plan and roll out new infrastructure to maximise our capital output whilst still providing enough beds in the most holistic way possible.

Healthcare design in South Africa, as in many other parts of the developing world, has had to focus on becoming more adaptable by encouraging flexibility of spaces within the clinical environment. Although this idea comes with its own set of complexities, it is the most likely manner in which we can ensure both versatility and longevity of our healthcare facilities under limited budgetary constraints and in unforeseen circumstances. Adaptability is the key tool that will unlock effective and efficient healthcare environments.

The spotlight is also fixating on re-evaluating the interactive nuances of clinical planning, with special attention given to infection control measures and risk mitigation in the hospital environment. Therefore, it has become increasingly important for designers to immerse themselves in constant research of the clinical sphere, including recent research prepared by the World Health Organization in order to stay abreast in developing new ways of responding to clinical requirements. This is going to be a key area where the veteran designers in the healthcare sphere can open up discussions with clinicians and begin revisiting and translating our current design standards and norms.

In an effort to encourage holistic healing environments for long-stay and isolated patients, designers are relooking at the significance of introducing as much natural light and ventilation as possible. Designers are also considering reorganising spaces to create more defined public interaction nodes, reviewing how we design isolation units, addressing privacy thresholds more strategically and reassessing the viability of our material usage in clinical spaces.

In researching adaptable spaces that are clinically compliant, one needs to strongly reconsider our material selection and our finishing specification – with a synergy between the two being crucial – without compromising on quality of space. We need to invest in systems and specifications that allow us the freedom to rearrange spaces economically without compromising the clinical integrity of our finishes.

Architecture in a pandemic world is thus going to challenge us to think outside of our preconditioned understanding of what spatial planning in healthcare is about, forcing us to move away from the permanent, and reconsider the adaptability of space whilst still being cognisant of economic and clinical considerations.

6. Any comments or suggestions on temporary healthcare facilities?
There are two main categories for the temporary structures currently required, the first being quarantine sites which are not necessarily clinical environments, but rather hostel-like spaces for those in our communities that cannot self-isolate at home. Quarantine sites are much easier to make ready, and local municipalities and large corporations have taken big steps in assisting in the preparation of such sites.

The more complex requirement is the response to the deficit in clinical and ICU beds in both the private and public sectors. This deficit is however not just a local problem, but one that is globally evident.

Because of the services and spatial requirements for ICUs, the roll-out of such facilities, whether temporary or more permanent, is slower. It is thus questionable whether a temporary ICU is an effective approach or whether formal conversion and new ICU projects are more sustainable.

There is currently much discussion about the deployment of temporary ICU structures whilst spaces that are more permanent are being built. For now though, it will be a joint effort of the public and private sectors to manage where patients are admitted and how many existing beds can be converted and upgraded quickly to comply with ICU requirements.

A combination of different types of proposals is needed in the race against time, and I thus believe that efforts from all sides that include both field hospitals and existing facility conversions are the best way to move forward under the budgetary and time constraints.

Acknowledgement and thanks go to Chad Brandon Paul from Clinix Group for the information contained in this article.

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