Innovations in Hospital Architecture

Stephen Verderber

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136999772
• Edition: 1
• Topic: Architecture
• Subtopic: Architecture General

This indispensable reference book captures key recent developments in the rapidly evolving field of sustainable hospital architecture. Today's architects must provide hospitals which enable high quality care for diverse patient populations in carbon neutral care settings, and this book succinctly considers what needs to be done in order to meet that challenge. The contemporary hospital is viewed in the context of global climate change, the planet's diminishing natural resources and the spiralling cost of operating healthcare facilities.

Stephen Verderber considers the future of the hospital, and supplies a compendium of 100 planning and design considerations for the building type. The book includes twenty-eight case studies of built and unbuilt hospitals from around the world. These are grouped into five types - autonomous community based hospitals, children's hospitals, rehabilitation and elderly care centres and hospitals, regional medical centre campuses, and visionary (unbuilt) projects.

Beautifully and extensively illustrated with many photographs, diagrams and floor plans, this is essential reading for all architects, planners, engineers, product manufacturers, clients, healthcare providers and government agencies involved in the present and future of sustainable healthcare environments.

PART 1
Background

CHAPTER 1
Introduction

This book has been a decade in the making. When Healthcare Architecture in an Era of Radical Transformation was published in 2000 I did not expect it would take ten years to produce its sequel. The idea behind that book was to capture events in the final third of the twentieth century. For a few years thereafter I thought about expanding that book with additional chapters but eventually decided it best to leave well enough alone. It made little sense to extend a book about the last century into the new one. The date of its publication had been fortuitous, and anyway, the field continued to move forward at breakneck speed. In retrospect it was worthwhile to wait long enough for a companion volume to cover the first decade of the new century.

No one has ever accused me of being an apologist for the architecture of most hospitals. I do greatly admire what happens inside them, however. They are marvels of technology, of human accomplishment, and they represent the highest aspirations of the human spirit. But a hospital is not an island. I recall an essay I was assigned to read while an undergraduate in the late 1970s titled ‘A city is not a tree’ (1964), authored by an upstart named Christopher Alexander. In it, it was argued that cities are systems of interdependent subsystems. No one aspect is entirely autonomous of any other. All the parts must work together, or at least relatively well together – transportation systems, buildings, parks, commercial, educational, and civic places, and most importantly the simple, nondescript everyday places and events in our everyday lives. This was an abstract notion to me – weren’t trees a part of systems as well? Were they not a part of an ecosystem? Later, I would come to appreciate more fully Alexander’s thesis, especially when it was expanded into the seminal book A Pattern Language: Towns, Buildings, Construction, first published in 1977. Some years later, after having chosen to specialize in the field of architecture and health, I came to realize the far deeper meaning of his thesis although not until only relatively recently would it re-resonate within me with intense force. This happened after I witnessed the destruction caused by Hurricane Katrina in 2005. It was stunning to see at first hand what took hundreds of years to build and nurture, in the case of New Orleans (founded in 1718), could be taken away in a matter of hours. The interdependences are fragile between the myriad subsystems of a city even in normal times but especially in the aftermath of an urban catastrophe.¹

It is a painfully slow, arduous, and costly process to rebuild a city. It is an equally painful process to rebuild a city’s healthcare with the stakes now higher. A hospital/medical center can no longer think of itself as an island, or for whatever reasons exempt from its urban ecological context. It must now also demonstrate leadership in environmental stewardship from the building and campus scale to the intermediate scale of its neighborhood, to the scale of the city, region, and entire planet. It functions within a delicate urban ecosystem. In broader terms, the promotion of human health remains its core mission but with ecological health no less integral to the total equation. To ‘Do no harm’ now denotes far more than it did a century or even a mere decade ago: a hospital must cause neither human nor ecological harm. A hospital is not an island.

Challenges to human health and wellness

The global healthcare landscape is becoming flat. New trends spread from region to region faster than ever before. Medical procedures once unique to a particular country are now performed on every continent. The United States is by no means a paragon in terms of the health of its citizens. Every nation has lessons to learn and worth sharing with other nations. For decades patients have traveled to London from Cape Town for neurosurgery. Telemedicine now makes it possible for a surgeon in Boston to synchronously assist in an experimental surgical procedure being performed in Lima, Peru. Healthcare is becoming transnational, jumping across borders with more and more regularity. This poses many legal and cultural challenges but both trends are likely to continue. In the U.S. nearly 47 million people (including 8.1 million children) did not have health insurance in 2009. The U.S. however spends the most per capita on healthcare in the world, representing 18 percent of the nation’s total gross domestic product. This figure rose to $2.6 trillion in 2009, averaging to about $8,000.00 for every person. This is unlikely to decrease in the near future, as healthcare is something that people tend to want more of, not less. The demand for healthcare is elastic. Hospitals in the U.S. are the direct recipients of one-third of all total U.S. fiscal expenditures. Healthcare should not be tied to if someone has a job; it should be portable and travel with them wherever they go. We insure every car on the road; don’t all people deserve the same?

Despite high expenditures for health, the U.S. lags behind many developed nations who spend far less per capita on healthcare.² Hospitals charge and receive differing amounts for the services they render based on the third party reimbursor. Charges are often presented as ‘list price’ for hospital services, set at a rate to cover other patients who lack insurance, as well as institutional overheads, administration, and debt. The system is breaking apart, overwhelmingly skewed toward after-the-fact sickness care versus preemptive wellness care and prevention. It is an unsustainable system and certainly no model for the world to emulate, in its present form. This problem will become further exacerbated by a projected population increase in the U.S. of 135 million over the next 40 years. In the next decade if no structural changes are made to the system 9 million more Americans will lose their health insurance.³ Meanwhile, the mad dash to embrace the all-private-room hospital in the U.S. (and elsewhere to a growing extent) is to its critics a classic exercise in being out of synch with funding realities, carbon neutrality, and the escalating cost of construction.

It is axiomatic that architects follow the money. That is, they tend to gravitate to clients most able and willing to pay for something (of quality, one hopes). What defines quality? Is it justifiable to narrowly define quality in a work of architecture for health primarily in terms of its aesthetic/formal attributes? Mainly for the wealthiest patients? The plight of healthcare availability for underserved minorities is worsening in most parts of the world. There simply is not enough money to go around for each and every newly built hospital or clinic to be of publishable quality in terms of its so-called aesthetic integrity. It is highly doubtful whether the residents in the East End of London, in the Lawndale community on Chicago’s South Side, in the barrios of Caracas, or in the slums of Mumbai care much about whether their local storefront or neighborhood clinic is published somewhere in a glossy architecture magazine or book. In most cases, and for a litany of reasons, this is unachievable anyway. The first and foremost priority must continue to remain clear: to promote and advance the health and well-being of all individuals and populations everywhere in an ecologically responsible manner.

On the other hand, it makes equally little sense to define a high quality work of architecture for health in purely functional or non-aesthetic terms, either: that is, on only whether its design results in a higher level of patient safety and fewer medical errors without any concern for its attractiveness, aesthetics, or visual amenity. Perhaps a clinic’s miniscule construction budget allowed for few if any high-end aesthetic amenities. Do its staff and patients really care about how it looks as long as it succeeds in this regard? The fact remains that an aesthetically undistinguished design may yield positive health outcomes although its chances for publication in a professional media outlet are slim to none. Everyone knows that the world has more than its share of less-than-beautiful hospitals, and these alone could fill up many volumes.

A third option appears to be by far the better course of action: strive to achieve both at once. This is the challenge – to first and foremost promote community health through design and ecological responsibility. It should in and of itself be rewarding to provide Architecture (with a capital A) to those who would otherwise never be touched by it in their lives. There is no longer a place for mutual exclusivity in global architecture for health in this regard. Embrace diversity. Embrace user constituencies of all classes and income levels. Embrace racial diversity. Embrace the medically underserved in your community. Provide paid professional services as well as pro bono services to these individuals and groups. Become a leader in your community beyond your role as an architect, engineer, landscape architect, or whatever. We can all be lifelong students as well as teachers in this regard, current trends in healthcare architecture notwithstanding. A real danger exists that the nascent but growing evidence-based research and design movement discussed in the following chapters will be unable to overcome the digital divide that isolates the haves from the have-nots. Internet access will remain inaccessible to the poorest, most remote patients. What good to these would-be patients is it for their local hospital to be noise-free, aesthetically superior, afford a high level of privacy, be safe of medical and staff errors, and so on, if they lack access to it?⁴

Challenges to ecological health and wellness

One hears talk constantly about ‘sustainability’ but what does it really mean? The arguments are compelling but architects need to acquire a much better operative understanding of their work in the context of environmental ecology, an expanded knowledge of material ecologies and their effects, the capabilities and culpabilities of high technology as a fix-anything panacea for any problem, the social ramifications of technology, and a greater knowledge of environmental history. Architects tend to narrowly think of sustainability in solely an ecological context, or in economic terms. Rarely do they/we think of it in holistic terms, including supply–demand tensions over the earth’s limited, highly pressed resources. But clean air and water, a livable climate, and a healthy standard of living are not the only endangered elements in our social order we seek to sustain. Broader realms include community, psychological health, meaningful work, intellectual openness, individual and social empowerment, a sense of heritage and history, cultural diversity, art, and music. These dimensions of everyday life are interrelated.⁵ Poor healthcare policy inevitably damages not only humans but also local cultural traditions.⁶ Sometimes sustainable goals come into direct conflict, as when green development inadvertently jeopardizes historic preservation and conservation, or catalyzes cultural, racial, or social conflict.⁷ Architecture, as a blend of the humanities and the sciences, can provide an ideal forum from which adjacent disciplines can learn and from which we can in turn learn much.

Environmental critic Richard Heinberg, in his recent book Powerdown, points out that hydrocarbons have been both the greatest blessing and the greatest curse our species has ever encountered. Coal, oil, and natural gas have given us the Industrial Revolution but have also brought global warming, pollution, habitat destruction, and modern industrial-scale warfare. It is a deeply intertwined set of benefits and costs and this is what makes our dependency on fossil fuels so problematic.⁸ Engineers, trained as problem solvers, have a tendency to respond to the crisis in isolation from its holistic and ecological contexts. It is oversimplified to a simple cause–effect problem: if we are running out of oil, the solution is simply to discover a new energy source capable of substituting for fossil fuels. The reality is that unless humanity pulls back its demands on the earth’s life support systems a new energy source will make little difference. When viewed as an ecological and cultural problem, and not merely as an engineering or architectural problem, it is critical to focus concurrently on reducing population pressures on the planet, to slow the rate of resource depletion, reduce the rate of habitat destruction and remain cognizant of valued local cultural traditions. Hein...

Table of contents

• Contents
• Figure Illustration credits
• Acknowledgements
• PART 1 Background
• PART 2 Design
• PART 3 Case studies
• Notes
• Index