Abstract
Healthcare Is Changing—So Are Hospitals
As healthcare delivery around the world is constantly changing, hospitals have to undergo significant development in parallel. Demographic changes, new medical technology, drugs and treatment, digitization, and so on have a profound impact in hospitals as well as in our homes and in society as a whole. This means continuously new and different challenges for healthcare planners and architects. Future health(care) invites citizens to be active cocreators in their own care as it moves closer to their daily lives. Care will take place in a continuum stretching from the private home, senior housing, public and commercial buildings, and into outpatient facilities to the highly specialized hospitals.
A Design Manual—Hospitals, is a recent book in this topic published by Birkhauser Verlag AG. Authors are Cor Wagenaar, honorary professor, University of Groningen; Noor Mens, doctoral candidate, Eindhoven University of Technology; Guru Manja, cofounder and partner CEANconsulting; Colette Niemeijer, architect, CEANconsulting; and Tom Guthknecht, PhD, ETH Zürich. It is a large size and heavy (24.4 × 2.5 × 33.3 cm3—2 kg) hardcover book with an attractive and easy-to-read layout amid many pictures and illustrations.
The Latest Trends
The ambition with the book is to identify and describe the latest trends in hospital architecture. It tries to sort out underlying factors and how this affects the principles and requirements for planning of hospitals and other health facilities. Additionally, it aspires to instigate a heightened awareness among its readers and in that way also be a tool for change. The target groups are architects, hospital administrators and planners, medical specialists, and policy makers.
The authors start with two fundamental statements. The first point out that until recently, many architects and critics considered hospitals an architectural backyard far away from the profession’s hall of fame. Since then, however, the situation has changed entirely, and “hospitals are back in the front lines of architecture.” The other is more profound: “For quite some time, a paradigm shift has been underway […], inviting patients to take an active role in treatment […]”. This means that the patient’s experience of care and its environments becomes central and thus soft values such as safety, context, and continuity. This will, according to the authors, completely change healthcare and correspondingly hospital architecture.
Overview Healthcare Architecture
A Design Manual—Hospitals accordingly begins with the hospital’s primary challenge: including the patient’s perspective—the personal experiences of the people the hospital has been designed for. The first part, “Defining the Hospitals of Tomorrow,” introduces the identified paradigm shift: the transition to a new way of thinking that puts the patient at the center. The second part “Designing Hospitals” clarifies three phenomena of today that increasingly affect hospital architecture—(1) new ideas regarding the optimal distribution of care facilities (e.g., concentration in large hospitals complexes or a network of smaller buildings), (2) the concept of “care pathways,” and (3) evidence-based design. The third and fourth parts of the book are the core of what could be defined as a manual—namely, presenting how to design a number of functionally defined units that make up a hospital. Finally, in the fifth part, a selection of 40 recently built hospitals are presented with photos and plans in six categories: public hospitals, children’s hospitals, university hospitals, specialized hospitals, community hospitals, and rehabilitation clinics. The projects have, according to the authors and in line with the overall ambition, been selected because they “represent fundamental trends”.
The book is an extensive introduction to and overview of the subject area. It is successful in promoting hospital architecture and show what a complex, challenging, and interesting architectural field it is. The first and second parts of the book are both knowledgeable, forward-looking, and visionary. It starts as one could expect with a historical look back to be able to position the present with better precision. From this, it outlines how the situation for healthcare architecture is today and where it is heading. The manual part with its functional descriptions of different care units is very much up to date, a relevant compilation of what is being built today. The functional descriptions of different parts of a hospital are excellent. Illustrations are easy to read and explanatory. Coordinated colors and shapes make it comparable. The part is also dynamic in the sense that various alternatives to solutions and the reasons for different alternatives are explained, whether the explanation is historical, functional, or contextual. The 40 selected projects are mostly inspirational and sometimes relevant. Given that it typically takes about 10 years from programming and design of a hospital until the first patients can be received, several of them show ideas about healthcare design 10–15 years ago.
So, the overall judgment of the book is positive. We have used the book last semester as mandatory literature in the master’s course Healthcare Architecture at Chalmers, with positive feedback from students. Despite this overall impression, there are some weaknesses that could have gained from being further developed and thus made the content clearer.
Who Needs a Manual Today?
A manual—isn’t that very old fashioned when hospital design is changing so fast? Yes and no, there are many good reasons for this book to be very timely. In several countries, “normative” tools such as generic programs and manuals were used for designing hospitals (and most other complex buildings) from the 1960s and onward. It typically provided guidance of how to design standard rooms and units for different functions. The hospitals built during this period accordingly have a high degree of structural similarity.
However, in healthcare architecture, a movement from centralized to decentralized planning took place during the last decades of the 20th century. This change occurred with different strength and times in different countries. Driving force was a general movement in society toward decentralized decision-making. Responsibility for planning of hospitals was typically transferred from the state level to regional or local bodies or, in some countries, even to individual hospitals. Decentralization reduced the demand for central support and control. Hence, mandatory standards were abandoned and forgotten. In this “dynamic” planning situation, many organizations or networks developed their own planning processes and tools. For hospital design, specific reasons were furthermore that generic standards (manuals) was regarded as a preservation of old practices and also cost driving.
Today, following development from a “normative” to a “dynamic” planning model, there is a movement toward what you might call an “integrated” planning model. Capturing the continuous transformation of healthcare, and at the same time identify future needs and translating these into buildings, is the challenge. Many organizations and facility providers in healthcare are therefore striving to develop new planning processes that can handles today’s challenges and high speed of change. These new planning approaches need to build on coordinated and systematized knowledge from both best practice and research.
A manual, given a clear role in these new processes, therefore once again has an important role to play. Compiled and analyzed/reflected good examples lift experience-based knowledge from just practice to being “best practice.” The ambition with the book, A Design Manual—Hospitals, fits well into this need.
But Is it a Manual, Really?
A manual according to the Cambridge Dictionary is “a book that gives you practical instructions on how to do something.” The broad ambition to write a book that contains a project cavalcade of completed projects, a manual (how to design different parts of a hospital) as well as visionary parts, is indeed a real challenge. You are inevitably handling three different time horizons—what worked 10 years ago, what works today, and what might work in the future. After reading, the whole book rather comes out as an anthology with various aspects of hospital planning and construction than a manual. The rapid development in healthcare and its architecture, as described above, makes it difficult to live up to the ambition of a manual that handles three different time horizons simultaneously. Additionally, it is obvious that chapters are written by different authors with different views and skills. There is a gap between the contextual, visionary, and forward-looking chapters that describe the context and paradigm shifts and those who are firmly anchored in practical hospital planning. This underlines a disintegrated impression of the book.
A discussion about what a manual is today and how it is intended to be used would have been supportive for the reader. That could include a discussion about how the different parts are related to each other. If the importance of the design process and how it is managed had been more articulated, that would help in weaving the different parts together. Accordingly, the book would have benefited if the section Planning: An Integral Approach had been given a more prominent place, both content wise and structurally. Now this section is almost hidden a bit randomly between Wayfinding and Outpatient Department. Here, hospital design dilemmas are described in an insightful way as “a landscape of compromises”.
There is also a missing link between general knowledge—the manual part/functional descriptions of different units—and its specific application—the displayed built examples. One example is the layout of the single-patient rooms. In the functional description, advantages and disadvantages of different configurations—bathroom in facade, bathroom between rooms, and bathroom toward corridor—are investigated and commented carefully. The problems connected with bathrooms placed at the corridor side, and thus obscure the visibility between patient and healthcare personnel, are well described. However, most of the project examples have patient rooms of this type. It would be supportive for the reader if this was commented and problematized. Here is something to learn that would be valuable to capture by a discussion when we study actually built hospitals.
The importance of daylight for both patients and staff is thoroughly researched and is an important part of evidence-based design. Despite this, several of the U.S. examples suffer from severe daylight shortage. One of the projects even has a patient center for children without daylight. In the same hospital, the NICU (Neonatal Intensive Care Unit) department has single patient rooms but no facilities for parents to live 24/7 near their sick children. This is something that research has shown to be of great importance for the early childhood recovery and care period. In the new “European standards of care for newborn health” (2018), it is recommended that overnight stays are available for the parents of NICU. As a conclusion, the selection of hospitals illustrates the difficulties with showcasing good international examples for something that to a high extent is contextual—healthcare.
Many of the selected hospital projects also seem to be chosen more from an architectural than from a patient/functional perspective. The text describing the projects has a strong flavor of architects marketing material that is mainly descriptive, focusing on the project’s positive properties. The examples shown have beautiful facades and visually interesting exterior and interiors. But it is often difficult to understand and evaluate the plans as they are frequently presented with a combination of much too big a scale and high level of detail. Names on rooms are repeatedly lacking. Nevertheless, the whole ensemble can be inspiring and interesting as examples of how healthcare architecture again attracts the most successful architects internationally.
And, last but not least, although the book in its appropriation indicates the emergence of evidence-based design as one of its “raison d’être,” the references in the book are mainly to other professional books and publications and to a much smaller extent to research (according to my calculation, less than 10% of the references are peer-reviewed research publications).
The Future—Patients in the Design Process
The approach “Person-centered care” (not to be confused with “patient-centered care”) is not mentioned in A Design Manual—Hospitals. It is however a fully articulated and implemented approach, applied by healthcare organizations internationally in response to the identified paradigm shift. A question that rises is: will this person-centered care, that is predicted to revolutionize healthcare by having the nonexperts become part of their own care, influences the design of healthcare buildings? And further: will we consequently also have patient involvement as a standard procedure in the design of hospitals in the future? Probably, as that will be in accordance with the transformation of healthcare itself.
However, this raises a lot of questions. What happens when the patients take their place among architects and healthcare planning experts? What is then considered good hospital architecture? Is it the projects that architects show each other and that are published in architectural forums? Or is it the healthcare staff’s professional evaluations? Or even the patients’ experience of what they perceive as good hospital architecture? For some architects and other hospital experts, this can be equally scary as it is for doctors to have the patient as a colleague.
I think the opposite—with the patients in the design process, then maybe it finally will be possible to change the image of the hospital from a “healing machine” to the hospital as a caring institution that not only offers treatment, comfort, and support but also encourages patients to take responsibility. Then, the future hospitals probably will have the greatest possibility to best support cocreation and co-production of health and medical care between patients, their relatives, healthcare professionals, and other actors.
What is certain, however, is that when patients and citizens become operatively involved in the design of hospitals, good available knowledge is more needed than ever, both as knowledge base and as inspiration, to support patients to see beyond their experienced needs and wishes. And when this happen, the target group for the book A Design Manual—Hospitals will be further expanded to also include patients!