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"A functional design can promote skill, economy, conveniences, and comforts; a non-functional design can impede activities of all types, detract from quality of care, and raise costs to intolerable levels." ... Hardy and Lammers
Hospitals are the most complex of building types. Each hospital is comprised of a wide range of services and functional units. These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental inpatient care or bed-related function. This diversity is reflected in the breadth and specificity of regulations, codes, and oversight that govern hospital construction and operations. Each of the wide-ranging and constantly evolving functions of a hospital, including highly complicated mechanical, electrical, and telecommunications systems, requires specialized knowledge and expertise. No one person can reasonably have complete knowledge, which is why specialized consultants play an important role in hospital planning and design. The functional units within the hospital can have competing needs and priorities. Idealized scenarios and strongly-held individual preferences must be balanced against mandatory requirements, actual functional needs (internal traffic and relationship to other departments), and the financial status of the organization.
VAMC Bay Pines, FL
In addition to the wide range of services that must be accommodated, hospitals must serve and support many different users and stakeholders. Ideally, the design process incorporates direct input from the owner and from key hospital staff early on in the process. The designer also has to be an advocate for the patients, visitors, support staff, volunteers, and suppliers who do not generally have direct input into the design. Good hospital design integrates functional requirements with the human needs of its varied users.
The basic form of a hospital is, ideally, based on its functions:
- bed-related inpatient functions
- outpatient-related functions
- diagnostic and treatment functions
- administrative functions
- service functions (food, supply)
- research and teaching functions
Physical relationships between these functions determine the configuration of the hospital. Certain relationships between the various functions are required-as in the following flow diagrams.
These flow diagrams show the movement and communication of people, materials, and waste. Thus the physical configuration of a hospital and its transportation and logistic systems are inextricably intertwined. The transportation systems are influenced by the building configuration, and the configuration is heavily dependent on the transportation systems. The hospital configuration is also influenced by site restraints and opportunities, climate, surrounding facilities, budget, and available technology. New alternatives are generated by new medical needs and new technology.
In a large hospital, the form of the typical nursing unit, since it may be repeated many times, is a principal element of the overall configuration. Nursing units today tend to be more compact shapes than the elongated rectangles of the past. Compact rectangles, modified triangles, or even circles have been used in an attempt to shorten the distance between the nurse station and the patient's bed. The chosen solution is heavily dependent on program issues such as organization of the nursing program, number of beds to a nursing unit, and number of beds to a patient room. (The trend, recently reinforced by HIPAA, is to all private rooms.)
Regardless of their location, size, or budget, all hospitals should have certain common attributes.
Efficiency and Cost-Effectiveness
An efficient hospital layout should:
- Provide optimal functional adjacencies, such as locating the surgical intensive care unit adjacent to the operating suite. These adjacencies should be based on a detailed functional program which describes the hospital's intended operations from the standpoint of patients, staff, and supplies.
VAMC Albuquerque, NM
Flexibility and Expandability
Since medical needs and modes of treatment will continue to change, hospitals should:
- Be open-ended, with well planned directions for future expansion; for instance positioning "soft spaces" such as administrative departments, adjacent to "hard spaces" such as clinical laboratories.
Hospital patients are often fearful and confused and these feelings may impede recovery. Every effort should be made to make the hospital stay as unthreatening, comfortable, and stress-free as possible. The interior designer plays a major role in this effort to create a therapeutic environment. A hospital's interior design should be based on a comprehensive understanding of the facility's mission and its patient profile. The characteristics of the patient profile will determine the degree to which the interior design should address aging, loss of visual acuity, other physical and mental disabilities, and abusiveness. (See VA Interior Design Manual.) Some important aspects of creating a therapeutic interior are:
- Designing a "way-finding" process into every project. Patients, visitors, and staff all need to know where they are, what their destination is, and how to get there and return. A patient's sense of competence is encouraged by making spaces easy to find, identify, and use without asking for help. Building elements, color, texture, and pattern should all give cues, as well as artwork and signage. (As an example, see VA Signage Design Guide.)
For an in-depth view see WBDG-Therapeutic Environments.
Cross-section showing interstitial space with deck above an occupied floor
Cleanliness and Sanitation
Hospitals must be easy to clean and maintain. This is facilitated by:
All areas, both inside and out, should:
- Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to dark and light; marking glass walls and doors to make their presence obvious
A hospital is a complex system of interrelated functions requiring constant movement of people and goods. Much of this circulation should be controlled.
- Dedicated service elevators for deliveries, food and building maintenance services
Aesthetics is closely related to creating a therapeutic environment (homelike, attractive.) It is important in enhancing the hospital's public image and is thus an important marketing tool. A better environment also contributes to better staff morale and patient care. Aesthetic considerations include:
- Increased use of natural light, natural materials, and textures
- Use of artwork
- Attention to proportions, color, scale, and detail
- Bright, open, generously-scaled public spaces
- Homelike and intimate scale in patient rooms, day rooms, consultation rooms, and offices
- Compatibility of exterior design with its physical surroundings
In addition to the general safety concerns of all buildings, hospitals have several particular security concerns:
- Protection of hospital property and assets, including drugs
- Protection of patients, including incapacitated patients, and staff
- Safe control of violent or unstable patients
- Vulnerability to damage from terrorism because of proximity to high-vulnerability targets, or because they may be highly visible public buildings with an important role in the public health system.
Hospitals are large public buildings that have a significant impact on the environment and economy of the surrounding community. They are heavy users of energy and water and produce large amounts of waste. Because hospitals place such demands on community resources they are natural candidates for sustainable design.
Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy conservation standards that meet EPAct 2005 and Executive Order 13693 requirements. The Energy Independence and Security Act of 2007 (EISA) provides additional requirements for energy conservation. Also see LEED's (Leadership in Energy and Environmental Design) USGBC LEED for Healthcare
The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy, and may affect location and layout of workstations that handle medical records and other patient information, paper and electronic, as well as patient accommodations."
Among the many new developments and trends influencing hospital design are:
- A growing interest in more holistic, patient-centered treatment and environments such as promoted by Planetree. This might include providing mini-medical libraries and computer terminals so patients can research their conditions and treatments, and locating kitchens and dining areas on inpatient units so family members can prepare food for patients and families to eat together.
Relevant Codes and Standards
Hospitals are among the most regulated of all building types. Like other buildings, they must follow the local and/or state general building codes. However, federal facilities on federal property generally need not comply with state and local codes, but follow federal regulations. To be licensed by the state, design must comply with the individual state licensing regulations. Many states adopt the FGI Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed below as a resource, and thus that volume often has regulatory status.
State and local building codes are based on the model International Building Code (IBC). Federal agencies are usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's ABA Accessibility Standards takes precedence.
Since hospitals treat patients who are reimbursed under Medicare, they must also meet federal standards, and to be accredited, they must meet standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Generally, the federal government and JCAHO refer to the National Fire Protection Association (NFPA) model fire codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).
The American with Disabilities Act (ADA) applies to all public facilities and greatly the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG)
Regulations of the Occupational Safety and Health Administration (OSHA) also affect the design of hospitals, particularly in laboratory areas.
Federal agencies that build and operate hospitals have developed detailed standards for the programming, design, and construction of their facilities. Many of these standards are applicable to the design of non-governmental facilities as well. Among them are:
- Department of Veterans Affairs (VA), Office of Construction & Facilities Management Technical Information Library contains many guides and standards, including:
- Design Guides for planning many different departments and clinics, design manuals of technical requirements, equipment lists, master specifications, room finishes, space planning criteria, and standard details.
Products and Systems
See WBDG Health Care Facilities for generic health care facilities websites
- See WBDG Health Care Facilities for generic health care facilities publications
- SpaceMedGuide-A Space Planning Guide for Healthcare Facilities-a popular planning tool providing state-of-the-art planning methodologies, industry benchmarks, and planning tips.