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Manual Of Hospital Planning And Design-Garg Dewan

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The hospital of the future: rethinking architectural design to enable new patient-centered treatment concepts

• Original Article
• Published: 15 December 2021
• Volume 17 , pages 1177–1187, ( 2022 )

Cite this article

• Carlos Amato 1 ,
• Leslie McCanne 1 ,
• Chengyuan Yang 1 ,
• Daniel Ostler 2 ,
• Osman Ratib 3 ,
• Dirk Wilhelm 2 , 4 &
• Lukas Bernhard   ORCID: orcid.org/0000-0002-9729-8928 2  

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Today’s hospitals are designed as collections of individual departments, with limited communication and collaboration between medical sub-specialties. Patients are constantly being moved between different places, which is detrimental for patient experience, overall efficiency and capacity. Instead, we argue that care should be brought to the patient, not vice versa, and thus propose a novel hospital architecture concept that we refer to as Patient Hub . It envisions a truly patient-centered, department-less facility, in which all critical functions occur in the same building and on the same floor.

To demonstrate the feasibility and benefits of our concept, we selected an exemplary patient scenario and used 3D software to simulate resulting workflows for both the Patient Hub and a traditional hospital based on a generic hospital template by Kaiser-Permanente.

According to our workflow simulations, the Patient Hub model effectively eliminates waiting and transfer times, drastically simplifies wayfinding, reduces overall traveling distances by 54%, reduces elevator runs by 78% and improves access to quality views from 67 to 100% for patient rooms, from 0 to 100% for exam rooms and from 0 to 38% for corridors. In addition, the interaction of related medical fields is improved while maintaining the quality of care and the relationship between patients and caregivers.

With the Patient Hub concept, we aim at rethinking traditional hospital layouts. We were able to demonstrate, alas on a proof-of-concept basis, that it is indeed feasible to place the patient at the very center of operations, while increasing overall efficiency and capacity at the same time and maintaining the quality of care.

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Current healthcare systems around the world are characterized by the organizational principles of segmentation and separation of medical specialties. They are structured into departments and facilities which offer the best service in their respective field but are not properly coordinated or tightly linked to the rest of the healthcare ecosystem. Consequently, today’s hospitals seem more a collection of different “departments” and medical fields than a fully integrated cooperative and service-oriented facility. Each department uses its own workflow schemes or standard operative procedures (SOP), employs specially trained personnel, and runs its medical service in well-circumscribed and precisely defined structures and areas. Communication between disciplines is often limited to the absolute minimum necessary for coordination tasks, e.g., regarding forwarding of relevant patient information and time scheduling of examinations or interventions.

The current system requires patients to step from doctor to doctor and from department to department to collect the jigsaw puzzle pieces of their disease. It is a serious drawback of current hospital structures that patients often need to tell their medical history and symptoms over and over again to the medical staff of different disciplines and subspecialties. The request and scheduling of different diagnostic examinations across departments are often confined to a very succinct standard requisition, neglecting the exchange of any additional patient-specific information (e.g., the anatomical reconstruction after gastric surgery in case of a postoperative CT scan to rule out complications). This data that are essential for appropriate programming and interpretation of diagnostic procedures is often non-accessible to the physician performing the exams. We call this “incremental care” and in this traditional model, the patient is constantly moved around to receive care (Fig.  1 depicts an exemplary traditional patient’s pathway). While some of these issues could be addressed by optimizing the clinical communication and data storage infrastructure, we believe that by means of architectural choices it becomes possible to further benefit and simplify the necessary workflows and to reduce the amount of required technology.

Traditional Incremental “Patient to Care” flow: the patient is constantly being moved between departments, typically starting from clinical reception, followed by examinations, diagnostics, treatments, ward stays and other way stations. Due to the highly fragmented structure, a direct access of external parties, especially academia and industry, is aggravated

Current hospitals are organized around well-separated specialized clinics and expert units, which all by themselves are perfectly tuned for economically optimized and efficient use of their dedicated infrastructure (e.g., the operating room in surgery or the MRI in radiology) and make efforts to reduce the cost of personnel wherever possible. Profit has become the main driver of healthcare and everything else including patient satisfaction and even quality of care often comes as a second priority. However, financial profit is generally not assessed on a global scale of patient management services but rather on the level of subsystems and specialized services, with a focus on separated profit centers which results in higher global costs rather than reducing them due to inefficient coordination and consolidation of clinical pathways. “Service-oriented” care units refer more to medical services (or equipment) and teams providing dedicated care, rather than to patient-centered care facilities. This often results in inefficient workflows such as excessive and unnecessary time spent in waiting rooms, which is becoming prevalent in large facilities.

Although system optimization works well for a specialized and restricted field, e.g., a department or a single facility, the entire healthcare system has grown enormously toward becoming rigid, not-adaptive, and slow. It is not designed for the active prevention of disease, but for mere reaction in case an adverse health event or development arises. This approach entails that the patient suffers more overall, since diseases are allowed to develop and manifest themselves before they are finally diagnosed and treatment can be started. At the same time, the burden for clinical care facilities increases as well, since treatments become more complex and result in longer durations of stay. The preventive approach has been advocated for quite some time now [ 1 ] and its benefits have become very obvious during the recent Covid-19 pandemic [ 2 ].

Although “interdisciplinary care” and “overarching approach” represent typical buzzwords of modern treatment concepts, the integration of involved clinical disciplines remains on a low level. One notable exception is acute trauma or emergency management where any active action is focused on the patient and collaboration is crucial to handling critically vital situations. The growing field of emergency medicine could serve as a model for a more global paradigm shift, as an example of healthcare delivery that is, above all, patient-centered. In such a context, interdisciplinary communication is highly standardized involving all persons and services required for well-protocoled patient management scenarios. Services are brought to the patient, and not vice versa, and anything and everybody involved is geared to facilitate a fast and comprehensive treatment. It has been shown that the patient-centered multidisciplinary approach, at least for acute trauma, can save lives and is superior to traditional concepts [ 3 ]. So, one might ask whether such an approach could also be beneficial for other indications or even for general care? And if so, will this new concept maintain the current standard of care and the relationship between caregivers and patients?

As a central building block for addressing the issues described in the previous we present our new hospital concept that we refer to as Patient Hub . It envisions a truly patient-centered, department-less facility, where all the critical functions occur on one floor. While our idea is not intended to solve all of today’s hospital design flaws (and we are fully aware that one solution will never fit all models), we aim at providing concepts and tools to help re-think traditional designs.

We developed a novel, one-of-a-kind design concept for the hospital of the future. The envisioned facility is fully patient-centered and strives for a workflow-oriented design by clustering related functionalities and processes in defined hubs, all located on the same floor and in close proximity to each other. In order to demonstrate the effectiveness and added value of our proposed hospital architecture, we benchmarked this new concept against a traditional design. For that, we reconstructed both the Patient Hub and an exemplary traditional hospital layout using 3D simulation software and compared them with regard to workflow efficiency and patient satisfaction. For the initial analysis presented here, we chose a typical patient scenario based on a common real-world case.

The patient hub concept

Today’s hospital buildings are often fancier versions of the 1960s bed-tower-on-diagnostic-and-treatment podium model, with a lot of newer technology crammed inside. In accordance with the principle of decentralization, which is prevalent in many healthcare systems around the world [ 4 ], such environments are characterized by being divided into departments and individual silos, each possessing its own organizational structure (including permanent staff, assigned space and beds), optimized for operational and financial efficiency. The patient is moved around from place to place to receive care, instead of bringing the care and technology to the patient (e.g., infrastructure like CT or MRI is often inconveniently and remotely located in a different building, as illustrated by Fig.  2 ).

Functional stacking of (traditional) Template Hospital used for simulation comparison

In contrast, our Patient Hub concept is a radical departure from the way traditional hospitals are designed. It envisions a transformative “one of a kind” and truly patient-centered, department-less facility. We propose a highly centralized clinical layout, where all relevant medical fields of expertise are available within the same space surrounding the patient (see Figs.  3 and 4 ). They form clusters which contain functionalities of equal classes, as for example examination , out-patient care or administration . For the patient, the whole system has a single-entry point to simplify wayfinding and is designed to minimize patient movement. The centralized clinical layout brings together staff from all specialties to encourage clinical collaboration and care coordination, thereby stimulating health care performance [ 5 ]. Instead of facilities being distributed along the hospital, and most often on different levels or even buildings, the new design concept aims at achieving a logical and self-explaining layout by bringing together what belongs together. However, the vision of the Patient Hub encompasses much more than a traditional hospital: This new environment (or ecosystem) co-locates outpatient, inpatient, rehabilitation, wellness and prevention, ancillary support spaces, and industry (research and development) all under one roof. It is envisioned to be no longer just a site for the treatment of the sick but a health-oriented all-encompassing facility, which is achieved by implementing patient-centered structures and workflows as well as by an expansion of services to also incorporate prevention and wellness.

Re-imagined healthcare paradigm: changing from incremental “patient to care” approach toward a re-imagined “care to patient” approach

Concept diagram illustrating “all under one roof” collaborative Patient Hub concept

Instead of being department-oriented, the Patient Hub design follows a more functional approach. To avoid getting lost in the sub-channels of the system (different departments with specific ecosystems), the architecture is logically constructed and patient-centered. It features a single point of entry, and a central meet and commute “core” to which the relevant facilities (housing, examination, out-patient care, administration) are linked, just as the arms of a tree are joined to the trunk. For the reduction or even full avoidance of patient moves, the respective areas cluster the required functionalities on one site. This will be done irrespective of the affiliated department or responsibility. Instead of passing from the radiologic department in level A to cardiology in level D to complete the pre-operative check-up, the patent will now move from one to the other door, as depicted in Fig.  5 .

Re-imagined “Care to Patient” flow diagram indicating functional adjacency needed to deliver patient-centered care

By avoiding duplicating functionalities which today are replicated in every department (e.g., waiting rooms, registration area, observation area) the Patient-hub concept aims at saving space, simplifying patient pathways, and facilitating implementation and adaptation of new treatment concepts. While keeping this functional patient-hub design with all required functionalities being logically distributed on one floor, we envision different levels of the building to be adaptable to different patient needs and specialties, like surgery, medical treatment, rehabilitation, etc. (see Fig.  6 ).

Patient Hub functional stacking and 3D massing

Due to its horizontal layout and resulting space demands, the Patient Hub layout in its most essential form is best suited for freestanding greenfield hospitals. The hub floor of our current design requires an 8,000–9,000 square meter floor plate but can be scaled up and down depending on the number of beds and procedure space needed. Since a further increase of the horizontal expansion would start to contradict the goal of having a compact centralized hub with streamlined workflows and short routes, we instead propose to stack multiple independent Patient Hub units vertically. Thereby, it becomes possible to retain the compact size of each hub and keep all movements of a given patient on the same floor, while making more efficient use of the available building ground and increasing the overall capacity.

Patient scenario

Our exemplary scenario revolves around a patient being diagnosed for rectal cancer. First, the patient receives general examination and diagnostics according to current guidelines [ 6 ], which include endoscopy, pelvic MRI and CT. After physical examination, which, due to his age and existing comorbidities includes cardiologic assessment, the case is discussed in multidisciplinary consultations such as tumor conferences and the patient is scheduled for surgery. Preparation measures for surgery include obtaining the patient’s informed consent by the surgeon and anesthesia, as well as preoperative preparation such as bowel cleansing and blood tests. After the intervention, observation in the ICU is carried out for one day, before the patient is returned to the regular ward. In our scenario, an eventless postoperative course is observed, which is why only a chest x-ray is performed to examine the postoperative lung status. No other tests or assessment of anastomotic healing are undertaken. During the hospitalization, the patient has an interview with the surgeon, to discuss upon the results of surgery and eventually additional treatments, and another interview with the social worker to decide upon auxiliary measures. Finally, the patient is discharged from the clinic.

The case above describes a common situation that clinicians are dealing with regularly and is based on the organizational structure and standard operating procedures of a university hospital. We analyzed the necessary steps along this clinical pathway for a traditionally designed hospital. Even though we chose a complication-free course for our scenario, the resulting list of necessary steps contains 95 entries, many of which are describing a change of the patient’s location or time spent within various waiting rooms. Refer to Table 1 for an excerpt of this list.

Workflow simulation

Using the 3D simulation software FlexSim Healthcare™ (FlexSim Software Products, Inc., Orem, Utah, USA), we developed dynamic models for comparing various quality measures between our two different hospital layouts. FlexSim Healthcare is a standalone healthcare simulation product aiming to model patient flows and other healthcare processes. It is designed to help healthcare organizations to evaluate different scenarios and validate them before they are implemented. For that, one or several architectural models can be created, followed by the definition of patient journeys. During execution of the simulation, FlexSim can monitor data contributing to patient satisfaction, including the total time spent, time spent for each treatment, time proportion of receiving care, travel distances, etc. It can also be used to analyze staff and equipment utilization rates and help to balance staff workload and amount of equipment.

Modelling of architectural layout

We selected Kaiser Anaheim hospital, a traditional hospital with a similar size, to be compared to the Patient Hub. The construction of this hospital was based on a generic “template” hospital plan developed and used by Kaiser-Permanente, the US largest non-profit Health Management Organization (HMO) (Fig. 7 ). This plan was developed when the organization was required to replace half of its hospital beds in California due to new seismic regulations and resulted in a prototypical hospital “template” that can be built on virtually any site, with few modifications [ 7 ], with a minimum of effort, lead time, and government review [ 8 ]. The design aimed at incorporating the best known clinical practices and design success stories and was optimized for a fast and efficient construction process [ 7 ]. Due to these characteristics, and a broad and successful implementation, we have selected this layout as the best comparison available today.

Simulations within FlexSim Healthcare for a traditional hospital (Kaiser-Permanente); a 2D overview floor plan; b 3D rendering of 2nd floor; the right parts of the images show the linear workflow used for the simulation

The second model (see Fig.  8 ) represents our Patient Hub, i.e., a hypothetical department-less hospital layout based on patient-centered care activities and concentrated on a single floor. Both buildings were modeled in FlexSim based on the floor plans. The model elements essential to this process were those affecting patient travel distance and waiting time, including vertical transportation, wall arrangement and the available medical equipment.

a 2D view of main Patient Hub floor showing diagnostic and treatment, outpatient, universal inpatient patient ward and patient experience / public / interdisciplinary coordination core blocks; b 3D rendering of Patient Hub floor within FlexSim environment; showing simulation workflow study to determine and test ideal functional adjacencies

Definition of patient treatment journey

After implementing the models, we defined the patient scenario (see previous section) and created a list of healthcare services that this patient needs to receive. We programed the full process based on this list, from patient first entering the hospital, walking to each exam rooms, receiving direct care (endoscopy, CT, MRI, surgery), receiving indirect care (observation rooms, patient ward), consultation and rehabilitation, and finally leaving the hospital.

Definition of staff and equipment

We assigned medical staff (doctors, nurses, technicians, etc.), medical equipment (CT, MRI etc.) and transit equipment (wheelchairs, gurneys, etc.) to the simulation models. For each model, 2 CT machines, 1 MRI machine, 1 ergometer, 4 gurneys and 4 wheelchairs were available. The patients were supervised by 4 Doctors of Medicine (MD) and 4 Registered Nurses (RN) per medical specialty. Numbers were based on the size of the functioning area (according to industry standards) and are the same for both models in order to not affect the simulation results. We programed the full process of staff providing direct and indirect care including escorting and monitoring patients.

Using FlexSim we simulated the whole process from entering the hospital to exiting, and monitored key statistics including travel distance, major milestones, treatment times, waiting times, time proportion, utilization rate for both patient and staff. For both scenarios, we simulated the arrival of three patients every half hour between 8am and 9:30am, which amounts to a total of nine patients.

Comparative parameters

For measuring the performance of the two models, we selected multiple parameters, with a high focus on improving the patient experience:

Waiting and Transfer Time

Travel Distance

Number of Elevator Runs

Access to Respite Spaces, Nature and Quality Views

The first parameter Waiting and Transfer Time is arguably the most relevant for patient experience, staff workload and overall efficiency alike. By decreasing this parameter, the overall duration of the hospital stay can be shortened and resting/recovery time for the patient (i.e., time spent in the ward) can be maximized. Furthermore, staff members are less overburdened and can potentially use the gain in time for other tasks or patients, thus improving staff satisfaction and economic interests of the hospital. Admittedly, reducing transfer times likewise can serve to increase the throughput of patients, however, we did not intend to improve on this measure.

The parameter Travel Distance refers to the length of the path that each single patient needs to travel during the hospital stay. We split this into the following three parts reflecting the different stages of the patient’s pathway: Endoscopy , CT  +  MRI  +  Cardiology and Anesthesia  +  OR  +  ICU . Decreasing travel distance is desirable since long transfers between distant departments are a burden for patient and personnel alike and extend the duration of hospital stays.

Wayfinding refers to the complexity of the patient’s traveling route within the hospital. A high number of turns, stop-and-go’s, transfers paired with rather chaotic paths and destinations scattered across different buildings indicate a poor performance with respect to this parameter. Short and infrequent transfers paired with simple and uncomplicated routes within the same building and on the same floor indicate a good performance. For our initial assessment, we interpreted the patient’s path as a graph and used the number of nodes and edges as an abstract measure of complexity. In addition, we considered the number of locations requiring signage as a more user-oriented parameter.

The Number of Elevator Runs is another measure for the complexity of patient transfers. Elevators often are bottlenecks within hospital buildings and contribute to elongated transfer times, which is disadvantageous from patient, staff and economic perspectives. Therefore, a low number of elevator runs indicates better performance. Furthermore, elevator operation typically accounts for 3 to 8% of the total energy consumption of a building [ 9 ]. Thus, a decrease can have a positive impact on the hospital’s CO 2 footprint.

Hospital stays can be associated with high mental stress or anxiety for many reasons, such as individual ailments and separation from the outside world and everyday life. The bleak, functional and sterile look that hospital interiors tend to have, may further amplify this effect. However, there is overwhelming evidence and research indicating that having frequent Access to Respite Spaces, Nature and Quality Views influence our health outcomes and help mitigate this problem [ 10 , 11 , 12 ]. To evaluate the performance of our models with regard to this parameter, we analyzed the number of patient rooms, examination rooms and corridors providing quality views to gardens surrounding or located in between hospital buildings.

Numeric results of the workflow simulations for the parameters and models explained in the Methods section are given in Table 2 .

Our results presented in the previous section are promising, since a considerable improvement for every selected parameter can be observed. We see this as a proof-of-concept of our ideas. However, we want to stress that the investigated scenario is only a first step toward proving the feasibility of the Patient Hub concept. Other patient scenarios and combinations of them will lead to even more complicated situations and workflows, where we believe the benefits of the new patient-centered layout will become even more obvious—due to the reduction of bottlenecks and resulting improvements of target parameters relevant for patient experience. Generally, we interpret the simulation results as evidence for the postulation that, as healthcare strategies are expected to evolve toward more ambulatory and short-term hospitalization, facilities should focus more on optimizing their workflows rather than maintaining the priority of traditional inpatient procedures of hospitalized patients. Our study also concludes that a patient experience measurement or scoring system should be formally included in all hospital design simulations, although the construction of such an integrated index is still pending and requires the involvement of experts from different fields.

Clearly, the proposed layout has not yet been fully implemented in the real world and thus may be prone to problems that cannot be identified using the proof-of-concept approach presented in the manuscript. As of now, a test pilot project with limited scale is under construction in Philadelphia, which will accommodate 150 beds. This test project will be a valuable source of insights regarding problems and limitations of the Patient Hub concept.

Still, there are limitations that we are already aware of, especially regarding the size of the Patient Hub. It is neither reasonable nor feasible to scale up a single floor facility indefinitely to accommodate for more and more patients. The strengths of the centralized layout would be mitigated by the huge size and the whole system would presumably become sluggish and less efficient. Also, the available building ground would not be used very efficiently, as compared to a multi-level building. A possible solution to this is the stacking of multiple patient hubs (e.g., with different specializations) on top of each other. However, this would mean that diagnosis and treatment services need to be duplicated, which has been done in the past, but is not preferred by most hospital operators due to financial concerns.

A further limitation is that an integration of the Patient Hub concept into existing facilities is not possible. Thus, it is exclusively applicable to new building projects.

As of now, the proposed concepts mainly focus on architectural design and a translation to the real world will certainly require many more building blocks, such as AI (notably workflow scheduling/optimization), big data (collection and processing of health data) and robotics (e.g., self-driving assistance systems). In particular, we envision the entire infrastructure, including technical devices, spaces and functional units to become adaptive and mobile. For example, a medical / surgical patient room could be utilized as an ICU site (Universal Room). Intervention rooms could be suitable for surgery, interventional radiology or cardiologic manipulations. CT scanners and other assistance systems could be designed as self-navigating systems, to move independently to desired locations.

While we plan to incorporate such considerations into future work, we advocate a very deliberate use of technology, governed by the paradigm of bringing care to the patient and not solely by economic interests. As argued before, the new patient-centered approach is expected to increase patient satisfaction, to reduce overall procedure times (if combined with an intelligent real-time scheduling and organization system) and to even be superior regarding infection prevention. Moreover, such an adaptive environment will most likely contribute to the physicians’ satisfaction as well as foster collaborative and interdisciplinary work. At the same time, it will allow for fast and easy adjustment of the entire system according to the current number of patients and the prevailing diseases they are suffering from (e.g., in case of a pandemic). As shown in Fig.  9 , we envision the Patient-Hub to behave according to an expanding core model, where all activities can be centralized during times of low demand (e.g., at night) and expanded by reactivating auxiliary areas from hibernation to deal with higher workloads. A centralized layout would facilitate such an expansion and retraction as opposed to a traditional layout where all core functionalities are distributed throughout the hospital.

Functional design changes from a distributed pattern to an expanding core concept

The Patient Hub Design maintains the patient–caregiver relationship and the principle of patient-centered care delivery by preserving core aspects of current hospitals such as wards and operating theaters, which, however, are functionally rearranged and smartly repositioned within the Patient Hub. This rearrangement not only improves patient experience but also the patient-related communication and collaboration of physicians, further improving workflow and information exchange.

We believe “departments” will no longer define the basic structure of a hospital. Instead, patient requirements and functionalities, such as “operative care,” “infectious disease recovery”, “conservative oncology” or “preventive care” will be brought into focus. By using this revised interpretation of interdisciplinary patient-centered care for our Patient Hub concept, we are able to improve patient and healthcare workers experience and satisfaction while maintaining the current standard of care.

Lastly, we do not believe that economic parameters are deteriorated by the patient-centered approach. On the contrary, our simulation results show significant increases in efficiency throughout the facility, with less required staff members and less time required per patient. Therefore, we expect our approach to not only be beneficial for patients and employees, but to be cost effective and economically reasonable at the same time.

We have presented our vision of a novel patient-centered department-less hospital design referred to as the Patient Hub. While the realization of this vision clearly requires disruptive change regarding many aspects (such as clinical workflows, application of technology, functioning of the healthcare system in general), our main aim herein was to focus on re-inventing the architectural layout. For benchmarking the performance of our concept with regard to patient experience, we have defined a patient scenario and created simulation models for both the Patient Hub layout and a standard hospital template by Kaiser-Permanente. The simulation results were highly promising, showing clear advantages of the Patient Hub layout throughout all benchmark parameters. We see this as a proof-of-concept of our ideas and as an important validation before implementing the Patient Hub in the real-world.

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Carlos Amato, Leslie McCanne & Chengyuan Yang

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Amato, C., McCanne, L., Yang, C. et al. The hospital of the future: rethinking architectural design to enable new patient-centered treatment concepts. Int J CARS 17 , 1177–1187 (2022). https://doi.org/10.1007/s11548-021-02540-9

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Received : 06 July 2021

Accepted : 29 November 2021

Published : 15 December 2021

Issue Date : June 2022

DOI : https://doi.org/10.1007/s11548-021-02540-9

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Towards a resilient hospital design

Towards a resilient hospital design: Emerging design considerations for future healthcare facilities after the pandemic COVID-19

Pretelt Duque, Manuela (TU Delft Architecture and the Built Environment)

Delft University of Technology

Architecture, Urbanism and Building Sciences

COVID-19 has highlighted the importance of the healthcare systems in society. The pandemic overwhelmed hospitals and forced rapid and radical changes in healthcare organizations' working practices and management structures (MASS Design Group, 2020; Ramboll, 2021; Capolongo et al., 2020). The virus led to unfamiliar environments, new spatial configurations of hospitals were necessary to cope with the surge capacity, new protocols and strategies were fundamental to respond to the crisis. Past pandemics have occurred, and other infectious diseases and viruses might come. COVID-19 is not going to be the last challenging situation for the health sector. Thus healthcare systems could become more resilient. Hospitals need to be resistant to future outbreaks, maintaining and adapting critical functions during crises (Ramboll, 2021). It is essential to learn from the experience of the COVID-19 pandemic to be more prepared for future events. This practice-based research aims to gain insight into the pandemic experience to provide recommendations to future-proof hospital design. A qualitative approach is proposed for this study. First, through a general questionnaire, information on building adaptations and working practices of hospitals in the Netherlands during the pandemic was assessed. Then follow-up in-depth interviews with chosen facility and real estate managers that answered the survey would be conducted to reflect on the crisis period and understand the decisions and choices taken regarding planning, design, and engineering during the different waves in the country's hospitals. According to findings, the pandemic in the Netherlands increased cohesion and collaboration between healthcare organizations. The national government advised the coordination of the emergency response, and the decisions within each organization were driven by independent Crisis Management Teams (CMT). Clear guidance facilitated the decision-making process of the measures and services that needed to be implemented. In general, hospitals felt well prepared for the pandemic, although changes and improvements were made regarding building, technical and employee-focused modifications to respond to the surging demand of covid-care. Additionally, an analysis considering three spatial characteristics of hospitals: type, building year, and urban density, was done to determine if there was a distinction in the measures taken. It was found that most hospitals implemented some top measures and that there is also some differentiation between groups of hospitals. Based on the findings and the lessons learned from the interviews, some suggestions for future renovations and developments were made. Recommendations could help build up towards future-proof facilities to a virus-like COVID-19 increasing spatial flexibility, robustness and adaptive capacity of healthcare buildings.

Future hospital design COVID-19 pandemic response Hospital characteristics Building interventions Technical interventions Employee-focused measures adaptability flexibility Robustness Healthcare resilience

http://resolver.tudelft.nl/uuid:22b88828-2851-49e2-8b44-74b598522e08

Student theses

master thesis

© 2021 Manuela Pretelt Duque

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Why hospital design matters: A narrative review of built environments research relevant to stroke care

Julie bernhardt.

1 Stroke, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia

Ruby Lipson-Smith

Aaron davis, marcus white.

2 Centre for Design Innovation, Swinburne University of Technology, Hawthorne, Australia

Heidi Zeeman

3 Menzies Health Institute Queensland, Griffith University, Brisbane, Australia

Natalie Pitt

4 Silver Thomas Hanley (STH) Health Architecture, Australia

Michelle Shannon

Maria crotty.

5 Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia

Leonid Churilov

6 Melbourne Medical School, University of Melbourne, Parkville, Australia

7 School of Education, Health and Social Studies, University of Dalarna, Falun, Sweden

Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. How building design can best support healthcare services, staff, and patients is important to consider. In this narrative review, we outline why the healthcare environment matters and describe areas of research focus and current built environment evidence that supports healthcare in general and stroke care in particular. Ward configuration, corridor design, and staff station placements can all impact care provision, staff and patient behavior. Contrary to many new ward design approaches, single-bed rooms are neither uniformly favored, nor strongly evidence-based, for people with stroke. Green spaces are important both for staff (helping to reduce stress and errors), patients and relatives, although access to, and awareness of, these and other communal spaces is often poor. Built environment research specific to stroke is limited but increasing, and we highlight emerging collaborative multistakeholder partnerships (Living Labs) contributing to this evidence base. We believe that involving engaged and informed clinicians in design and research will help shape better hospitals of the future.

Introduction

Imagine (re-)designing the very hospital you work in. What would you design differently? What would you change, to benefit you, your patients, and their families? What evidence might help guide those design decisions?

Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. 1 Once built, hospitals remain in service for decades and are difficult to modify. With stakes this high, considering how building design best supports healthcare services is important. In this narrative review, we outline why the built environment matters, with particular focus on stroke care. We also discuss challenges inherent in designing healthcare environments, undertaking research and evaluating completed architecture.

The planning and design process for new healthcare environments is incredibly complex, but, in general, it occurs in three overlapping stages: (1) the planning stage in which the healthcare provider describes the users’ needs, model of care, and clinical program in a functional brief that summarizes the requirements for the new hospital; (2) the design stage in which these requirements are interpreted by architects to develop an initial concept which is then refined to a more detailed design; and (3) the delivery stage in which the building is constructed. The extent to which hospital staff and patients are included at each stage of this process can vary significantly between projects. 2

Healthcare professionals have long advocated for design features thought to benefit health and well-being, such as natural light, ventilation, and space between patients—for example, the circular hospital design proposed by the physician Antoine Petit 3 and long “Nightingale wards” proposed by Florence Nightingale. 4 Hospital design is now informed by a process termed “evidence-based design” (EBD), in which research evidence is used alongside other considerations such as the healthcare context, budget, and architects’ experience, to inform the design of the healthcare built environment. 5 , 6 In this context, the “healthcare built environment” encompasses: (1) the physical construction (layout, room dimensions, doors and window placement, outdoor and community access, etc.), (2) ambient features (noise, air quality, light, temperature, etc.), and (3) interior design (furniture, signage, equipment, artwork, etc.). 7 Analogous to evidence-based clinical practice, hospitals designed following best research evidence garnered from EBD processes have better safety, patient outcomes, staff retention, and operation costs. 8 , 9 The Center for Health Design, established in 1993 to advance EBD, now maintains a repository of over 5,000 articles on healthcare design ( https://www.healthdesign.org ).

The field is growing; however, many healthcare contexts, including stroke, have a limited built environment evidence base. 10 Establishing geographically organized stroke units has been an important focus 11 ; however, these studies rarely address specifics of the built environment, and we know little about optimal stroke unit design. Stroke clinical guidelines rarely mention the built environment nor provide guidance on how the environment might best support care. There are currently no stroke care-specific building standards, nor standardized checklists to evaluate the quality of these environments. 12

Why is the built environment neglected? Clinicians may identify as knowing less about how the environment might influence patient care or staff well-being. They may also feel uninformed about the design process and how to contribute their clinical expertise to influence decision-making. To begin to address these gaps, our objectives for this review were: (1) to introduce readers to healthcare built environment research and (2) to highlight evidence that underpins acute, subacute, or rehabilitation stroke care facility design. This review is in three parts:

• Overview of healthcare built environment research;
• Stroke care built environment evidence; and
• Planning and design of new healthcare environments: Challenges and opportunities.

We include research from recent, relevant systematic reviews, other evidence summaries, and selected qualitative and mixed-methods research focusing on healthcare environments and design. Healthcare environments are complex and context-specific, with many interdependent variables that can rarely be isolated. This complex system does not readily lend itself to highly controlled experimental research designs in real-life settings. 13 Qualitative methods, such as case studies and pre- and post-occupancy evaluations (before and after a redesign or redevelopment), are common. With research still developing, heterogeneity exists in research designs, outcomes, environments, populations, and theoretical frameworks employed. 14 Hence, robust summary evidence derived from meta-analyses is lacking.

Healthcare built environment research

Research is dominated by studies conducted in acute environments such as emergency, surgery, and intensive care units (ICUs) ( Figure 1 ). 6 , 15 , 16 Older people, including those in dementia care, are frequently studied post-acute populations. 17

The volume of built environment research conducted in different healthcare settings. Circle size indicates the number of published research articles based on systematic literature review in preparation 18 and articles listed in the Centre for Healthcare Design research repository. Pink circles represent all built environment research, and the dark gray circles indicate stroke-specific research. (The aerial sketch in this image has been adapted with permission from Architectus + HDR.)

In this section, we introduce three topics relevant to most healthcare contexts: (1) design of internal spaces; (2) outdoor spaces; and (3) ambient features including light, noise, and air quality (with particular focus on infection control).

Internal spaces

The design of internal spaces, such as ward configuration, corridor design, and nurse station placements (centralized vs. decentralized), can influence patient visibility, safety, teamwork, distances staff walk in a shift, and time spent providing direct care to patients. 10 For example, open-plan, larger convex spaces can lead to greater patient visibility, and corridor width impacts staff circulation, informal communication, and teamwork. 19 In ICU, designs with centralized nurse stations and visibility of most patient rooms from that location are increasingly being replaced with decentralized nurses’ stations, arguably without strong evidence. 19 In emergency departments, with similar critical visibility requirements for teamwork and patient monitoring, some authors argue that physically separated zones or “pods” are neither efficient nor safe. 20 Decentralized nursing stations can lead to more patient room visits by staff. 21 , 22 This highlights current uncertainties.

The layout of hospital spaces and line of sight influences patient and visitor orientation and their ability to find their way around (“wayfinding”). 23 Signs, information boards, and “landmarks” (artwork, furniture, views, etc.) are typical wayfinding elements. 24 , 25 Inadequate wayfinding leads to delays in accessing services or finding people or places, associated stress, and higher staff burden as they provide directions for lost individuals. 25 While some standards exist, wayfinding is often not optimized in healthcare. 26

The proportion of single versus multiple(two or more)-bed rooms is a prominent ward design consideration. There is evidence that single rooms can support staff/patient communication, privacy, infection control, and noise reduction, but they are also associated with patient isolation and increased falls risk. 27 This evidence is, however, of mixed quality, limited to certain populations, with neutral and/or contrary results. 27 A higher proportion of single rooms generally results in longer corridors, longer staff walking distances, perceived decrease in patient visibility due to compromised sightlines, and higher construction and cleaning costs. 28 The inherent trade-offs will be different in every healthcare context. Less controversial is location of sinks and hand sanitizers; highly visible and standardized positioning promotes more consistent use. 29 , 30

Outdoor spaces

Hospital gardens were historically commonplace 31 ; however, less priority has been given to green space over time. Access to the outdoors and time in nature has been linked to stress reduction, improved physical symptoms, and emotional well-being in many healthcare settings. 32 Views of nature have been linked to reduced length of stay. 33 Good hospital garden design principles include creating opportunities for exercise, exploration, socialization, and to engage with and escape in nature. 32 Surprisingly, patients and visitors are often not aware of hospital gardens, and proactive approaches to increasing patient and family use of gardens have been recommended. 34 Usually conceptualized as spaces for patients and visitors, staff are often their primary users. 32 Outdoor spaces can be restorative for hospital staff, helping to reduce stress and improve attention, which may improve patient care and staff retention. 35

Ambient features

Ambient features, such as light and noise, can impact patient well-being and comfort, sleep, and communication with staff. 36 , 37 Light and noise also impact staff well-being and attention 38 and contribute to medication errors and other safety concerns. 39

Air quality is important for both comfort and infection control. Infection control is particularly prioritized in acute environments and is receiving deserved attention in the COVID-19 pandemic. A recent review of COVID-19 transmission showed that spatial configuration can affect patient density and thereby transmission. 40 Optimized systems for heating, ventilation, and air conditioning (HVAC) can filter microparticles such as viruses. Different HVAC systems also affect humidity, airflow velocities, air pressure—all important for exposure to active aerosols. Window ventilation, daylight, and electric UV light are recommended to aid disinfecting surfaces and use of surface materials that affect pathogen survival. 40

Stroke care built environment evidence

In this section, we outline how the built environment can influence important outcomes such as: (1) evidence-based stroke care, including rehabilitation; (2) efficiency of stroke care, staff processes, and communication; and (3) patient safety and well-being. The evidence-base specific to stroke care is small. 41 In Figure 2 , we summarize the design features and how they may influence a range of outcomes including patient and staff behavior. This should be considered illustrative rather than exhaustive. Where possible, we draw directly from stroke or brain injury-specific evidence, supplementing evidence from other populations where relevant.

A summary of the evidence specific to stroke care environments. Dotted lines = a hypothesis, garnered from research in other populations; thin lines = limited evidence, < 3 studies; thick lines = moderate evidence, ≥ 3 studies, based on systematic literature review. 41

Evidence-based practice including rehabilitation

We found no stroke-specific research to underpin built environment recommendations for optimal delivery of either time-critical acute stroke treatments or evidence-based care, including rehabilitation. Guidelines recommend early commencement of both structured and incidental physical, cognitive, and social activity for all stroke patients, 42 , 43 although recommended levels vary. Patients in both acute and subacute environments spend most of their day alone and inactive in their bedroom. 44 , 45 While we can hypothesize that providing “draw-them-out” features on a ward may improve activity and engagement, evidence is limited. These features may include green spaces and indoor communal (social) spaces. Unfortunately, communal spaces, when present, often appear to be underutilized in both acute 46 and rehabilitation environments. 47 Many factors may influence whether patients use communal spaces, including not knowing they exist or where to find them, difficulty accessing them without help, or feeling they don’t have permission to use them. 48 In a Norwegian study across 11 stroke units with communal areas, patients were more active and spent less time in their bedroom in units where meals were served in the communal area. 49 Providing resources (games, music, books) in personalized activity packs and in communal spaces (“environmental enrichment”), with the aim to improve physical, social, and cognitive activity, has recently been tested in acute and subacute settings with mixed results. 50 – 52 Importantly, this approach relies on staff to encourage use and engagement, rather than embedding activity opportunities into the building itself. Hallways and circulation spaces are generally underrecognized as providing spaces for incidental activity and interaction. 53

There is limited stroke-specific research about the value or harm of single- versus multiple-bed rooms. A higher proportion of single rooms may be associated with lower levels of patient activity in acute stroke. 54 , 55 A systematic review of single- versus multiple-bed rooms in older people and those with neurological disorders found potential benefits (e.g. infection control, patient satisfaction) and harms (e.g. falls, isolation) with single rooms. 56 In rehabilitation facilities with a high proportion of single rooms, patients emphasize the importance of communal areas. 57 Further work is needed to identify and test how modifications to layout and communal and circulations spaces could enhance patient engagement, activity, and optimal care provision.

Efficiency of care, staff processes, and communication

Interprofessional communication and teamwork between physicians, nurses, and allied health professionals supports best practice stroke care. 11 Shared staff spaces support team communication and collaboration, enabling better understanding of patient needs, and greater knowledge about other team roles. 58 , 59

Therapy spaces are often discrete locations (e.g. gym, occupational therapy rooms), rather than being holistic, context-based environments that reflect the connectivity and continuity necessary for rehabilitation and transition beyond discharge. 60 , 61 Separation of clinical and therapy spaces can impact staff travel time, patient practice and activity, and even clinical decision-making. For example, Blennerhassett et al. 47 found that patients spent less time engaged in physical activity and more time in corridors when the ward was located further from the gym, on a separate floor. This also impacted wheelchair use and patient travel time. 47 Inaccessible therapy spaces can also change therapists’ intervention choices. 62

Safety and well-being

Falls are common after stroke, 63 yet the relationship between the built environment and falls is largely unexplored. The presence of a fellow patient (multiple-bed room) may help reduce falls, especially for older patients with neurological injury. 56 , 64 Roommates play an important role in monitoring the physical and mental health of others in stroke rehabilitation. 48 Stroke patients often experience loneliness when in hospital, 65 , 66 and some patients will choose a shared room over the privacy of a single room. 57 Sleep is important for recovery. Unsurprisingly, visual and aural privacy is less in multiple-bed rooms. However, noise traveling between corridors and bedrooms and lack of dedicated staff spaces for confidential conversations are also important. 48

Planning and design of new healthcare environments: Challenges and opportunities

Healthcare environments research and design is a multistakeholder endeavor involving government, healthcare providers, managers, clinical staff, patients, architects, quantity surveyors, construction companies, building managers, etc. This collaborative process can be challenging, 67 , 68 considering interdisciplinary differences in knowledge and approaches. 69 The complexity of hospital procurement and the fact that design and construction processes are foreign to many healthcare professionals adds further challenge. Clinicians often do not understand what the “user group” consultation process is supposed to achieve, and their involvement may be inconsistent throughout the design process, which limits their contribution to the process and ability to influence decisions. 67 While collaboration between architects and healthcare professionals is not new, 70 limited evidence informs current consultation processes. 67 , 71 High-quality healthcare environments are produced when shared decision-making and collaboration happens across healthcare, construction, and architecture to create designs based on evidence and end-users’ perspectives. 69

A number of research approaches are suggested to facilitate this collaboration, including participatory design, co-design, and Living Labs. 2 , 72 , 73 Over many years, our team has built partnerships between healthcare environment practitioners, clinicians, researchers, and people living with stroke, which have served to create a common understanding of the barriers and opportunities for redesigning and optimizing stroke care environments. With the creation of the Neuroscience Optimized Virtual Living Lab (NOVELL) for stroke rehabilitation redesign ( www.novellredesign.com ), we are working to develop new models for stakeholder engagement and research, and to contribute new evidence to stroke rehabilitation design.

In addition to collaboration challenges, research is infrequently embedded in the planning and design of new healthcare environments, and leaders in EBD have long called for appropriately funded, transparent, and freely available evaluations of completed buildings. 74 – 76 Given the cost of constructing and running healthcare buildings, the absence, or non-disclosure, of evaluations to determine whether desired outcomes were met is concerning. 77 , 78 Hospital design and construction is underpinned by technical and generic building guidelines and standards that differ within and between countries. The degree to which these standards are “evidence-informed” varies. In stakeholder consultations, understanding what is evidence-based and what is open to change can be difficult. Design innovation is essential if hospital buildings are to respond to new healthcare models or processes. For example, the recent COVID-19 induced surge in utilization of telehealth and other e-health technologies for rehabilitation, other treatment, and communication with people with stroke has implications for healthcare design, increasing demand for spaces for videoconferencing, equipment storage, and potential changes to waiting rooms and on-site consultation spaces. 79 , 80 Future design considerations for stroke recovery should also extend to the home environment. 81

The built environment matters. It can impact healthcare delivery and patient and staff outcomes. An evidence base is growing in some areas of healthcare design, while others require significant further research. The potential for both hospital and health services design innovation is strong. By continuing to build this evidence base, EBD can complement architectural processes to deliver high-performing healthcare assets. Involving engaged and informed clinicians in built environment design and research will help shape hospitals of the future.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: NOVELL is funded by the Felton Bequest and the University of Melbourne. Julie Bernhardt is funded by an NHMRC Research Fellowship (1154904). The Florey Institute of Neuroscience and Mental Health acknowledges support from the Victorian government and in particular funding from the Operational Infrastructure Support Grant.

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Planning, Analysis and Designing of Multi-Speciality Hospital Building | IJSRDV6I90054

2018, IJSRD - International Journal for Scientific Research and Development

— The aim of the project " Planning, Analysis and Design of Multi-Speciality Hospital Building " is to develop a multi-speciality hospital building with economical design using manual design techniques and computer aided design. The project summary report emphasizes the structural analysis and design finding of hospital building. The main scope of this project is to apply class room knowledge in the real world designing of a hospital building there building require large and clear area unobstructed by columns. Here the hospital building is of four story RCC structure with 300 no. of beds and capacity of 22500sq.m which is planned using AUTOCAD for floor plan and STAAD PRO for analysis. The multi-speciality hospital building is located in Avadi. The basic requirements of hospital building is taken from): IS 12433 (part3-2001) and the member are designed using IS 456:2000.

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