Guidelines In Planning and Design of Hospitals
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.
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:
- Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces
- Allow easy visual supervision of patients by limited staff
- Include all needed spaces, but no redundant ones. This requires careful pre-design programming.
- Provide an efficient logistics system, which might include elevators, pneumatic tubes, box conveyors, manual or automated carts, and gravity or pneumatic chutes, for the efficient handling of food and clean supplies and the removal of waste, recyclables, and soiled material
- Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas, and by making prudent use of multi-purpose spaces
- Consolidate outpatient functions for more efficient operation—on first floor, if possible—for direct access by outpatients
- Group or combine functional areas with similar system requirements
- 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.
Flexibility and Expandability
Since medical needs and modes of treatment will continue to change, hospitals should:
- Follow modular concepts of space planning and layout
- Use generic room sizes and plans as much as possible, rather than highly specific ones
- Be served by modular, easily accessed, and easily modified mechanical and electrical systems
- Where size and program allow, be designed on a modular system basis. This system also uses walk-through interstitial space between occupied floors for mechanical, electrical, and plumbing distribution. For large projects, this provides continuing adaptability to changing programs and needs, with no first-cost premium, if properly planned, designed, and bid. The VA Hospital Building System also allows vertical expansion without disruptions to floors below.
- 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:
Using familiar and culturally relevant materials wherever consistent with sanitation and other functional needs
Using cheerful and varied colors and textures, keeping in mind that some colors are inappropriate and can interfere with provider assessments of patients’ pallor and skin tones, disorient older or impaired patients, or agitate patients and staff, particularly some psychiatric patients.
Admitting ample natural light wherever feasible and using color-corrected lighting in interior spaces which closely approximates natural daylight
Providing views of the outdoors from every patient bed, and elsewhere wherever possible; photo murals of nature scenes are helpful where outdoor views are not available
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.
Cleanliness and Sanitation
- Hospitals must be easy to clean and maintain. This is facilitated by:
- Appropriate, durable finishes for each functional space
- Careful detailing of such features as door frames, casework, and finish transitions to avoid dirt-catching and hard-to-clean crevices and joints
- Adequate and appropriately located housekeeping spaces
- Special materials, finishes, and details for spaces which are to be kept sterile, such as integral cove base. The new antimicrobial surfaces might be considered for appropriate locations.
- Incorporating O&M practices that stress indoor environmental quality (IEQ)
All areas, both inside and out, should:
- Comply with the minimum requirements of the local disability accessibility laws.
- In addition to meeting minimum requirements of ADA and/or GSA’s ABA Accessibility Standards, be designed so as to be easy to use by the many patients with temporary or permanent handicaps
- Ensure grades are flat enough to allow easy movement and sidewalks and corridors are wide enough for two wheelchairs to pass easily
- Ensure 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.
- Outpatients visiting diagnostic and treatment areas should not travel through inpatient functional areas nor encounter severely ill inpatients
- Typical outpatient routes should be simple and clearly defined
- Visitors should have a simple and direct route to each patient nursing unit without penetrating other functional areas
- Separate patients and visitors from industrial/logistical areas or floors
- Outflow of trash, recyclables, and soiled materials should be separated from movement of food and clean supplies, and both should be separated from routes of patients and visitors
- Transfer of cadavers to and from the morgue should be out of the sight of patients and visitors
- 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.