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Journal of the Academy of Hospital Administration

Patient Focused Architecture - An Art and Science

Author(s): Sunil Kant*, Shakti Gupta**

Vol. 14, No. 2 (2002-07 - 2002-12)

Key Messages:

  • Hospital architecture is an essential facet for patient well being and recovery.
  • Life enhancing design strategies should incorporate primeval forces of Nature.
  • Existing norms of architectural design specifications in healthcare facilities need a revaluation.

Introduction

In the recent past, healthcare has become one of the most challenging and dynamic activity. Patient is the focus of all activities in a healthcare institution and for efficient effectivity their needs coupled with those of visitors and staff should dictate the strategies including those of hospital architecture. Encompassing architecture as an enhancer for patient sensory experience has as much of a positive impact on clinical effectiveness and performance levels as high technology medicine. Research has proved that well designed hospital environment can have a substantial impact on patient recovery and welfare1.

Hospital Architecture - An Art or a Science?

Medicine is a cultural as well as a scientific pursuit. Science is an organized body of knowledge based on exact principles. It establishes a cause and effect relationship and its findings apply repeatedly in all situations2. Hospital architecture fulfills criteria for a science categorization. Art on the other hand is bringing about of a desired result through the application of skill. Like other professions e.g. medicine and management, hospital architecture practice is an art. Hospital architecture is also a creative activity. According to LH Sullwai,3 "A building being an embodiment of life should be conceived as the sum of all material, spiritual, intellectual and emotional activities within the building." Much of the hospital architecture strength comes from the intense regards for the need of patients, staff and visitors. The age old essence of architecture viz respect for function, structural integrity, awareness of time, integration with environment and expression of meaning are still valid. Though UNESCO3 has reclassified architecture from art to social science, hospital architecture does still remain an amalgamation of art and science. In case hospital architecture is restricted to antiquated specifications and cook book approaches to framing regulations, planning freedom will be converted into a bureaucratic rigidity. A complete scientific, standardized and inflexible planning means freezing of development. Repetition has been the great enemy of art4. The art and science of hospital architecture dictates that the environment should restore the dignity of patients, offer comfort and safety to visitors, staff and patients.

Patient Focused Hospital Architecture - A Sine-qua-non

A building without comfort, safety and appropriate atmosphere has no significance as architecture. There is a difference between good architecture and the mere act of building. Hospitals are differentiated and highly specialized institutions. The healthcare buildings are to be designed as living spaces for families than warehouses for the sick. The hospital system cannot remain viable if the needs of the patients are not holistically visualized, analyzed and fulfilled. As the primary function of hospitals is to take care of patients, their needs should directly dictate every care function otherwise the mechanics will become an end in themselves. Departmental and organizational needs may siphon off the resources and energy. Planners must be aware of the ideology of the community. Attitudes, aspirations and values must be clearly understood. Hospitals must be planned for the future. All dimensions of security and risk including those related to fire hazards, thefts and physical harm should be addressed. A hospital is not a factory in which the assembly line dictates all aspects of design but is a community in which the patient is fundamental to the successful working of the whole2.

Design Strategies to Assist Healing

Designing a conducive environment for patients requires knowledge of the associated social, economic and technical facets. The design strategies to assist healing should be non detrimental and facilitating. Patients needs, satisfaction comforts and expectations should be given due consideration. There is ample evidence that exposure to nature has a positive healing effect. The primeval forces of nature - Sun, Wind, Earth and Water, all have a mystifying positive effect and enrich the environment. The architecture plan should offer humanistic patient services and a setting for efficient, technologically advanced facilities. Master planning should be organized, flexible and have future growth potentials. It should be patient focused, adjustable to individual needs, capable of absorbing the dynamics of changing situations and embracing new systems. Sense of familiarity and association through home like surroundings should be co opted. Innovation just for creating a change or a fad could be detrimental if the physical, philosophical and humanitarian aspects of healthcare institution are not understood. Macro and micro planning must receive due, appropriate and timely consideration. Hierarchy of requirements, necessities and solutions much be conceptualized, analysed and enunciated. There should be a continuum of care from cradle to grave and across a spectrum of services. The diversification, customer orientation and excellence should be for all levels of healthcare delivery - Primary, Secondary and Tertiary. The design and planning should focus on all types of patients - very sick, sick, early sick and the worried well. The healthcare institution should be a safe place for patients. Non skid floors, safe staircases, emergency exits should be planned. Based on studies conducted by Carpman Grand Associates, Environment Design consultant,5 hospital patients and visitors share the following basic design related needs

Physical Comfort such as Appropriate Lighting.

Social contact deals with personal privacy - limiting what others see and hear of oneself as well as controlling what seas and hears of others.

Symbolic meaning encompasses the array of non- verbal messages embodied in design e.g. crowded waiting spaces and inefficient house-keeping are negative symbolic's for patients and visitors.

The important parameters which must be considered are as follows:

Sound:

Architecture should incorporate positive use of sounds. Natural sound, particularly water have a calming and relaxing effect and should be gainfully employed in the form of fountains, artificial springs/water falls or rivulets. Music as a de-stresser and healer should be utilized. Appropriate requisites for piped music should be incorporated in the architectural design.

Light/Colour:

Intensity, colour, and temperature of light source are important parameters. Architecture design should not lead to direct glare which causes eye fatigue and loss of concentration. Elderly people need three times more light than young adults for the same activity. Colour is particularly important in design for the elderly, since they lose sensitivity to the blue (short wave length) end of the colour spectrum. General room lighting may be from sources along the perimeter walls as light coves underneath air conditioning ducts to provide diffuse light, accented by spotlight colour wherever required. Attributes include hue, (dominant wave length), brightness (luminance) and saturation (purity of wave length). Colour can act as a visual stimulator, volume enhancer and relieves the monotony of prolong confinement of patients.

Nature:

There is ample evidence to prove that exposure to nature has a positive healing effect. Ulrich's well-known study6 of surgical patients showed a shorter length of recovery and fewer complaints from patients with a nature view. Fire, water plants, fish tanks, views of nature and access to gardens have been used effectively. There should be ingenuity in creating pleasing views/spaces in continuation with Natures' wealth. Landscaping should be planned with indoor - outdoor continuity principle. Sustainable architecture caring deeply about the environment should be the focus.

Future Modalities - From Vision to Reality

As we usher in the 21st century the design and layout of hospitals will change to be in tune with the times - effective functionally and economically. Technological advancements will aid in creating conducive environment for the care givers and patients. It is a known fact that the patients negative and positive experiences in a medical environment have residual effects on the healing and care processes. In patient focused architecture the parameters which define quality of the healing environment are space, privacy, comfort, variety and communication. A David Medical Foundation Study5 on the design of hospitals had stated that the ill patient is apprehensive and anxious. Stress stimulates a defence mechanism. The patients long for privacy. Physician patient relationship can blossom in privacy. Privacy should not be confused with isolation. Variety should always be provided in the planning and design of the healing environment since everyone benefits from a breath of fresh air, from a change of scene, from going to the outside world and from seeing beyond the confines of the rooms7. Some of the emerging concepts are:

Existing and Future Norms:

Traditional norms will have to be reconsidered. Established norms cannot be applied universally. Norms are guidelines and should be suitably modified. As has been rightly commented3 "building codes reflect and perpetuate the technology of some earlier period. They restrict the potential use of new ideas and materials. Standardization must not result in making planning an affair of geometric ordering, a game of grids." A standard design never strictly satisfies the local demands. Patient focused operational restructuring/reengineering will be needed in healthcare institutions. Emerging trends in environmental requirements must be fulfilled. Resources permitting, at least some rooms should be single occupancy to accommodate demands for privacy and other patient requirements. The wall adjoining the central corridor should preferably be glazed to enhance visibility. Built in closets for patient belongings, recliner chair/fold out bed for family members and an adjoining toilet shower room may be some of the favourable facilities. Rooms maybe spatially and visually interconnected through various wall cut-outs, void and glass screens to mitigate the feeling of enclosure. Partial height walls for stimulating and soothing environment will be an useful aid. Four to eight bed multiples with flexibility to accommodate varying staffing levels by specialty or acuity level may be functionally more efficient. The use of light weight partition with sound insulation properties would ease the problem encountered during addition/alteration. Modified Rigs pattern of cubicles are preferred over the traditional Nightingale wards8. These smaller suites should have immediate access to lounge facilities, library/educational materials, kitchenette and conference facilities for patients families/visitors and caregivers.

Fig 1. Depicts the percentage of space for patient room, ancillary/support services and staff support in a traditional and futuristic inpatient unit.

Figure 1
Fig.1 Inpatient Unit-Present and the Future

High volume routine ancillary services should be organized into decentralized system operating from core spaces on each patient floor. A larger amount of clinical/support space will be required on each patient floor than traditional nursing units9. It is emphasised that different facilities are required for various levels of care i.e.. Primary, Secondary and Tertiary.

Life Enhancing Designs:

Our desire to enhance the quality of life is being translated into an ever widening array of arenas, including the built environment to humanize our architecture. The psychological and aesthetic needs of patients in addition to their physical requirements must be given due consideration. Gradually we are developing an understanding of the link that exists between intention, consciousness and our built world, as research continues to indicate that our environment indeed affects and influences our behavior. Life enhancing design has been defined as "a place built or created to support and sustain the well being of a particular occupant of time, place and culture where the body as a whole both inner and outer is regarded as essential to how the space is expended." The various parameters for life enhancing designs are10.

Body Centred vs Image Object Centred:

The dynamic relationship with the environment is the basis for manifesting an architecture that privileges the person and is body centred. It is the design that is focused around the intellectual and the emotional experience of a person rather than being stylistic that has no conscious connection to context, environment or people.

Multisensory Vs Single Sense:

Our sense connects us intimately to the world through the relationships of mental and physical phenomenon to our inner and outer perceptions. The augmented sensory experience affects the psychological and physiological dimensions.

Integrated Medical Office Building (MOB):

The integration of MOB into hospital facilities ensures efficient, effective and user friendly healthcare delivery. The Aspen Centre in California, an OPD surgical unit has encompassed the integrated MOB concept11. The centre elicits the openness and vitality required to form a sense of well being for patients and visitors and epitomizes the rapid change occurring in today's healthcare delivery system. A brief description of the facility reads "The modernist, sleek bronze-reflective glass and post-tensioned building structure sports impressive two-story glass enclosed elevator within a mall with fountains, notable works of art and plantings which combine to give the patient a sense of wellness that blends with the area's progressive and friendly spirit." Even some of our corporate hospitals have incorporated integrated MOB concept effectively.

Vaastu Shastra-Fad or a Science?

Everyone suddenly seems to be talking about "Vaastu Shasta". The relevant queries raised are, Is it a superstition? A passing fad or just a buzzword? Has it applicability to healthcare institutions?

The living place of "Deviates" and human beings is known as "Vaastu" derived from the word Vaastu (Matter). "Vaastu Shilpa Shasta" refers to the field of Vedic architecture in which architecture is considered the art of creating the living environment. "Vaastu' is "Prakruti', a sanskrit word meaning a surrounding, environment matter or nature and utilizes the five basic and essential elements of the earth - the "Pachabhuutas", viz "Aadaasha" (space), "Vaayu" (air), "Agni" (fire), "Jala" (water) and "Bhumi' (earth). There are five fundamental principles of vedic science of architecture12. They are:

  1. "Diknirnaya" - doctrine of orientation.
  2. "Vaastu Pada-Vinayassa" - site planning.
  3. "Manna - Proportionate- measurement of Haastalakshana" building.
  4. "Aayaddi Sadvarga'- six canons of vedic architecture.
  5. "Pataakaadi Sadschandas" - aesthetics

"Vaastu" and "Feng Shui" have various principles and advocated practices which have been dismissed by rationalists as obsolete, unscientific. Interpretation by experts/practitioners also seems to differ significantly. However some principles of "Vaastu' may be gainfully employed in healthcare architecture planning and designs. The theory of orientation lays emphasis that maximum beneficial effects of solar radiation should be obtained. Eastern frontage of buildings aids in obtaining the beneficial effects of solar spectrum including those of ultraviolet light. In spectrum planning (Vaastu-Pade-Vinayassa) a square is a model depicted in Fig 2. East is attributed to the Lord of light (Sun), west to the Lord of winds (Varun), north to the Lord of wealth (Kubera) and South to inanimate. Fig 3 depicts the siting of hospital services as per the above configuration. Wards having a eastern frontage will benefit from the good effects of the sun and the western side maybe gainfully utilized for ventilation.

Figure 2

Fig 2 "Vaastu-Pada-Vinayassa" - Site Planning

Manna. i.e. proportionate measurements in terms of height, length, breadth, thickness and inter space have been elaborately enumerated in Vedic architecture since strict adherence to measure was considered to have a fundamental metaphysical implication. The principles are applicable and maybe gainfully employed in healthcare architecture. "Aaya" i.e.. measurement of building may also be suitably applied in hospital architecture e.g. "Gajaaya" "Aaya" are good for stores. i.e. those buildings where the product of length and breadth multiplied by factor 9 and divided by 8 yields a balance of 2. This yields a good configuration for storage facilities.

Figure 3

Fig 3 Applicability of "Vaastu-Pada-Vinayassa" - to Hospitals

"Feng Shui' considered as a pseudophysical science of climatology and geomorphology, originated in China and denotes the terms "wind" and "water". While "Vaastu Shastra" was developed in India to suit Indian conditions, some claim, Feng Shui to be an off shoot of Vaastu which was suitably modified to suit Chinese conditions. There are however basic differences between the two. While in Vaastu Shastra, the north is considered auspicious, as per Feng Shui, north problems arise from the north. The art of Feng Shui is closely related to the "Yin" and "Yang" - the negative and positive principles of universal life13. The same principles are also utilized in the Chinese system of medicines. From "Feng" (wind) to Sui (water) one discerns the gaseous elements of the environment (air, wind, ventilation, air conditioning) or its liquid aspects (rain, drainage, sanitation's), all within the ambit of present day architecture practice.

Conclusion

Modern hospital is like a living organism and hospital architecture as the art and science of building should be proactive to the continuing rise of patient expectations. Modern hospitals should not only allow but also stimulate good healthcare. The ambience should be cheerful and inviting, the environment caring and healing14. Hospitals may have to be built or re-engineered with a view that global healthcare transformation will continue to accelerate, moving ahead to enhance the delivery of the healthcare in the years to come. It will be provided in facilities planned and built today. As has been aptly commented3 "tomorrow is born out of today." In hospital architecture the cardinal principle "design follows function" still remains ubiquitous. However a purely functionalist tradition undervalues a more holistic attitude towards the physical environment. There should be a blend of technology and style to produce a human environment. The whole setup should be harmonious and should inspire a sense of health and well being. New hospitals should ensure buildings will offer a patient focused environment and a contribution to local and global environment. The patient focused parameters should be appropriately planned and incorporated in architectural designs of Primary Health Centres, Community Health Centres and multi speciality healthcare institutions. A patient friendly hospital atmosphere should be created by rational, articulated and harmonised facility planning by interaction between professionals and the target user groups. Patient focused care will dictate the design of healthcare facilities. Bricks and mortar alone do not make an outstanding hospital. A symphony will be created if a little heart and soul is added to this brick and concrete.

References

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  2. Koontz; O'Donnel: Weihrich. Essentials of management. 1st ed. London.: McGraw-Hill International 1996.
  3. Putsep E. Modern hospital international planning practices. 1st ed. London: Lloyd-Luke Ltd. 1979.
  4. Duchamp M cited in John Cage ed by Kostelannetz R. London: The Penguin Press: 1971 XVIII.
  5. Preiser, Wolfgang F.E. "Facilities Programming" McGrow-Hill Inc.1990.
  6. Janasses JO. Design strategies to assist healing. Asian Hospital. 1995. Mar/Apr 95.
  7. Barley DJ, Leissner GT. The future modalities of the acute services. Asian Hospital 1997. Vol II No. 5: 16-19.
  8. Varghese T. Need oriented ward design: Medical journal armed forces India, 1999; 55:56-56
  9. Hayward C. The inpatient unit of the future. Asian Hospital. 1994. Nov/Dec:30-31
  10. Crisp B. The nature of life-enhancing design. Asian Hospital. 1998:36-38
  11. Outpatient surgery centre and MRI facility Aspen Centre Administrated\Des\Lindblad Architects - Aspen Centre. html.
  12. Rao DM. Vastu shilpa shastra and Indian Tradition. 6th ed. India: SBS Publishers 1996.
  13. Lip E. Chinese geomancy. Reprint 1st ed. Malaysia: Times Books International 1996.
  14. WHO Regional Publication District Health Facilities; Guidelines for Development and Operations western pacific series No.22;1998. pg 205.

* O/o DGMS (Army), New Delhi
** Addl. Prof. Deptt. of Hosp Admn., AIIMS, New Delhi

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