“Guidelines and Health Care Buildings” Fani Vavili, Dr.Architect, Professor
Abstract
What are guidelines, why we need them, by whom they are
introduced? These are some of the questions that are
intended to be approached in this presentation. Apart from
the services they offered to the design process and the built
environment especially in the health care facilities the main
discussion today is if guidelines, norms, standards are
necessary tools in healthcare design or they act as barrier
in the creation of a proper healing environment
I. What are guidelines? A guideline is a general term.
Several types of Guidelines rule the hospital:
• Regulations (and government regulations): conforming
to rule or imposed standard; prescribed by rule or law,
prescribed rule or order
• Specifications: detailed statement of work to be done,
detailed list of orders
• Norms: recognized standards
• Standards: desirable level of efficiency
• Instructions: orders or directions
II. The main objectives of guidelines are to harmonize
and integrate in planning and design process a number of
factors. Specifically the nature of the hospital, its
momentous (complex) role, its users, the basic necessity
for reliability (security, safety, responsibility, etc.) and also
the need to control cost determine guidelines that are
Ø
aiming
• at the creation of an acceptable hospital (Health Care)
building
• at the achievement of a safe, orderly and expeditious
hospital (Health Care) building and
• that the result signifies an economic hospital building
National Guidelines also introduce norms, regulations etc in
order to
• clarify health care needs
• define priorities within economic limitations and strict
budgets and
ensure that the final product (health services and the
building) represents the best value for money
Rikshospitalet Oslo, 2001
Medplan AS Arkitekter
III. By whom, for what
reason.
Guidelines have a long
story since the Greek
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
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temples, the Roman constructions and Vitruvius etc. But
this presentation will be focused on guidelines for health
care facilities. Ministries of Health introduce the basic and
most relevant guidelines.
Legislation and Circulars that are applicable to hospitals are
introduced also by several Ministries such as
• the Department of Housing: Building regulations,
• the Dep. of Environment: Environmental regulations,
Fire regulations/codes
• the Dep. of Transport, etc.
Several Ministries introduce standards and guides but also
by other
•
governmental bodies e.g. SPRi in Sweden, Stakes in
Finland, British Standards Institution, German Standard
Institution (DIN), etc.
• professional organizations e.g. National Association of
Architects in Sweden, AAHA (American Academy of
Hospital Architecture) etc.
• Local Authorities and County Councils, published also
directories
• Disability alliances circulated design guides, rights
handbooks, etc
Plenty of publications (books, special magazines, guides)
by researchers, architects, architectural practices.
These guidelines, codes, specifications, measures, design
guides, etc. give necessary information starting from A and
arriving to omega at the alphabet of the steps needed in
order to create a hospital. The available information is so
abundant that you can find even details for a garden layout
suitable for wheelchair users (Lockhart, T,). For example a
Checklist for the bathroom design in order to ensure
convenient living for an elderly and physically handicapped
includes 17 recommendations: descriptions of materials,
flooring details, width of the door, etc. (Brancon, G., pp.47)
Several Department of Health and Social Security around
the world have studied and introduced Health/Hospital
planning
Notes,
Health/Hospital
Building
Notes,
Health/Equipment Notes, Health Technical Memorandum,
activity Data Base etc.
Rikshospitalet Oslo, 2001
Medplan AS Arkitekter
V. A. Hospital, Baltimore
Cochran, Stephenson,
Donkerviet, Inc.
Krankenhaus, Erfurt
Germany
Rossmann + Harder
IV. Guidelines content. The last fifty years there was, in
most countries, a huge increase of guidelines for hospitals
than for any other building type. The hospital design and
construction became subject of the most demanding
regulations and codes (planning, design, construction).
The various guidelines cover
• regional planning (hospital network)
• functional aspects (location and access, space data
etc.)
Rikshospitalet Oslo, 2001
Medplan AS Arkitekter
Nursing Home
Leibnitz, Austria
Klaus Kada
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
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psychological factors – stimulation of the senses
(colours, noise, odour, human scale, predictability,
safety (security, fire protection, floods, earthquakes…),
• privacy and independence (maintaining medical
supervision), etc.
• comfortability: temperature, seating etc., visual access
to the outside environment, etc. Gallup, pp.115)
• materials
• morphological and esthetical aspects (match with the
surroundings, human environment, symbol or identity,
etc.)
All these data are compromising and requirements are
minimum. They certify compliance of the design proposals
and accordingly the facility, to an essential, acceptable
minimum. They certify also those main functions and their
relationships; circulation principles, etc. are applied.
•
Standards, norms, etc. are products of their time and they
are the answers to pressing problems. Since the
technology changes quickly they have to be subjects to
continuous reform so the planner and designer to be aware
of their validity.
Greenwich General Hospital
London,
Tatoon Brown - DHSS
V. The stereotypes. The urgent need, especially in
Europe after the second world war, to develop health
facilities had based on a great deal of research resulted
huge amount of information. Hospitals, until recently, have
been studied in depth in order
• to avoid mistakes,
• to reduce time from the moment of the decision to
create a hospital until the opening day,
• to control cost and
• to involve more architects in the design process
All these factors drove hospital researchers and
governmental bodies (technical services at Ministries of
Health) to introduce also prototypes (Prototype: earliest
form of a layout, of a hospital, a model, a pattern).
For example the British Harness Hospital Development
program, the Nucleus templates, the Green Pack and the
Nucleus Hospital overruled, not only in U.K.) hospital
planning and design and for a long time prevailed over
hospital architecture.
The architectural drawing board when designing hospitals
had, and still has, a prototype for a room, a group of rooms,
a department, and even a whole hospital.
I will give here an example of a similar strategy applied in
Greece, a country of almost 10.000.000 people, from where
I come. During the 80’s the development of primary care
facilities became an urgent governmental policy in the
frame of the country’s National Health System. The
construction of 200 Rural Health Centers in a period of 4
years, was planned on basic decisions which were: a) to
involve as many architects and engineers in the design
process, b) to control the quality of design and c) to reduce
construction cost. In order to achieve that the technical
services of the Ministry of Health introduced detailed
guidelines, they gave also prototype layouts (in the way of
functional diagrams).
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
Wexham Park Hospital
UK, Powell & Moya
Best Buy Hospital
Frimley Park UK
HDP & DHSS
Huddinge Hospital
Stockholm
Chelsea Westminster
Hospital, London
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Two problems flourished through that: the prototypes
became stereotypes and the guidelines became an
obstacle to any architectural innovation. The planning and
the design became an exercise of geometry and
combinations of the given guidelines and the prototypes. It
can hardly be found through such a number of buildings a
few interesting architectural solutions.
Copenhagen Denmark
The matter is when a prototype becomes a stereotype,
which means that something is reproduced without
variations. Even the variations on given prototypes which
architects with agony try to apply in their synthesis are
limited and usually they are reproduced with dull uniformity
VI. National guidelines, if still have to exist, must be in
harmony with each country’s reality. It is crucial to avoid
coping, without criticism, norms from other areas.
Developing guidelines it has to be considered, apart from
specific requirements of the various departments:
• Cultural aspects,
• environmental conditions,
• the climate,
• building
specifications
and
local
construction
techniques
• the economy and financial aspects so the level of the
lowest cost (usually desirable) must be moderated to a
long-term advantage.
• Pilot studies
Wiener Allgemeine
Krankenhaus
Universitatsklinken
VAMED Group
Neukolln, Berlin
Klaehues + Konig
VII. Where we are today
There are traditional transatlantic differences. In Europe the
strong role of central and regional governments in
healthcare provision tended to encourage tangible and
quantifiable progress in medical technology and
management sometimes to the detriment of the overall
healing experience. Public servants ultimately accountable
to elected politicians and taxpayers were reluctant to spent
money on such intangibles as good architecture.
Other parameters also have been developed as basic
factors in hospital design. The idea that environment can
perform a healing function by reducing psychological stress
was introduced the last two decades.
The last decade there is a growing freedom in designing
hospitals. Hospital architecture has been returned more
than ever in the mainstream of architecture. It seems that
this movement started here in USA. New models of health
care delivery expressed with new design concepts. The
‘mall’ model, the “hospitality” model, the “residential”
models seem to facilitate current health services which are
directed more to patient as a consumer of medical services
and to market forces.
In Norway since the 90’s, as Knut Bergsland said, in a
workshop with similar subject than the one we discuss in
this session, at EU Health Property Network meeting in
Oslo last June, there are no guidance available in designing
hospitals. What they do? Architectural competitions,
learning from project to project.
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
Krankenhaus, Weimar
Germany, Ott Arch
Krankenhaus, Erfurt
Germany
Rossmann + Harder
Krankenhaus, Aachen
Weber+ Brand
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In Finland, according to information given by our colleague
Heli Kotilainen, the general Land Use and Building Act
(from 1 January 2000) covers all kind of buildings, also
health care facilities. There are a few special chapters for
health facilities i.e. the size of a fire compartment, sound
insulation, ventilation etc. Regulations, which are based
directly on acts, have to be followed, complementary
guidelines are not obligatory but local authorities will check
them when building permission is applied for.
In Germany the whole hospital design is supported and
controlled (Gaterman) by DINs and other specifications and
the involvement of architects of good background resulted
to the creation of a number of pioneered, interesting and
advanced hospitals.
In Netherlands, as Luub Wessels develops in detail (UIAPHG Seminar Volos 2001), apart from the existence of
guidelines, the collaboration between designers and
authoritarian public bodies gave the last decade avantgarde health care buildings. That means that there is
continuity in the production of hospital buildings. How that
can be achieved? Either by central control (e.g. in countries
with national health systems) or by architectural firms
(specialist expertise) with strong reputation in healthcare
design and construction (e.g. Ellerbe Becket in USA). Both
directions resulted at the selection of a designer, which is
the crucial step.
At the same seminar in Oslo Susan Francis speaking about
Design Criteria included guidelines, standards, norms but
also the impact of the facility: urban and social integration,
form and external appearance, character and innovation,
internal environment, etc.
It seems that these are criteria of good architectural design.
In the attempt to bring hospital architecture in the main
stream of architecture the support of schools of architecture
and interior design and postgraduate courses on healthcare
facility planning and design are needed urgently.
Kreiskrankenhaus,
Meissen, Germany
Worner + Partner
Spandau, Berlin
Heinle+Wischer+Freie
Finally norms, standards are seldom revised after a certain
period (5 years is considered a maximum). There is a lack
of national research in such matters for many reasons
especially today.
VIII. Conclusions
Medical services are undergoing a dramatic transformation
and the designs of healthcare facilities reflect these radical
changes. “Patient focused” or “patient centered” facilities,
the decentralization of diagnostic and treatments, the coordination of medical team etc is the new concept. But still
many design aspects remain the same.
• Design for future change has been the critical factor in
health care architecture for as long as we can
remember. Today the discussion is for more elasticity
• Design for value by balancing cost, quality, aesthetics
and access still is one of the first principles.
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
MRI, University Hospital
AHEPA, Thessaloniki
Vavili+Papathanasiu
Hopital de Zone
Yverdon, Suisse
Suter + Suter Arch
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•
•
The creation of friendly environment, the therapeutic
values of the environment and facilities as tool and
healer are basic principles incorporated in design
Green facilities or sustainable healthcare buildings
(materials that are non-toxic, environmentally
sustainable solutions, energy conservation, etc) are
lately more into consideration and in Europe necessary
by laws into public buildings.
There is so much information! ((Nesmith, E., Malkin, J.,
Torrington Judith, Miller, R & Swensson, E. etc. see
bibliography).
Where are guidelines for health facilities headed next? This
issue is connected to the future of healthcare facilities and
services trends and it is not easily addressed.
The detailed guidelines on every aspect of design which
followed by designers and administrators in public bodies in
countries with centralised health care systems and their
uniformity is no longer tolerable in decentralised, market
orientated healthcare culture (World Architecture: The
architecture of the feel-good factor)
There are also certain health subjects like deinstitutionalisation of mental health where the solutions
must be individual on a basis of basic principles.
Nursing Home, De Stichtse
Hof, Laren, Holland 1994
Albetrs & Van Huut Arch
Also guidelines often become an excuse for the lack of
architectural inspiration or for a poor architectural result.
Today the involvement of inspired architects in the design
of hospitals around the world is increasing.
Papanikolaou Hospital,
Thessaloniki
Vavili-Tsinikas Arch
Even so someone could discuss that standards assure a
minimum quality level and guidelines are in need. And the
quest for excellence still remains a target.
I recommend shortly that guidelines must be:
Generic and High Level (General Principles,
Operational Issues, Data collection and Lesson
sharing)
• Flexible (compatible, expandable, adaptable, elastic)
• Based upon existing Health Care Building Regulations
etc. in each country or region
• Built upon criteria that ensure out of the art facilities
(good architecture, excellent…)
• Developed and Disseminated by responsible bodies
e.g.
IHF, UIA-PHG, AHA, AAHA, EU Property Network, National
Technical Services and other bodies
Universities: Architecture, Interior Design, Environmental
Psychology, Regional and Urban Planning, Management,
Structural - Mechanical and electrical engineering, etc.
specialized in Health Care Buildings
•
Because the intention is the creation of Out of the
Art Health Care Facilities which is our business
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
Diabalcaniko Hospital,
Thessaloniki
Wilhelmina
Kinderziekenhuis, Utrecht,
Holland
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Bibliography
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American Institute of Architects (1993) Guidelines for
Construction and Equipment of Hospital and Medical
Facilities. Washington, The American Institute of Architects
Press
Brancon, Gary (1991) The complete Guide to Barrier-Free
Housing. Croset USA, Betterway Publ.
Bush-Brown, A. & Davis, D. (1992) Hospitable Design for
Healthcare and Senior Communities. New York, Van
Nostrand Reinhold, pp. 210-213
European Union Health Property Network, fifth meeting, Oslo,
June 2003
Gallup Whaley, Joan (1999) Wellness Centers. Wiley series
in healthcare and senior living design. Canada, John Wiley &
sons.
Hans – Evert Gatermann. Management Of Areas In The
Process Of Updating And Upgrading General Hospitals, pp.
75-83, ed. Del Nord, R. ed. (1996) Continuity Updating and
Upgrading Of Existing Health care facilities: XVIth IPHS
Florence. Polistampa Firenze
Lockhart, Terence (1981) Housing Adaptations for Disabled
People: a guide for architects, occupational therapists, and
householders. London, The Architectural Press.
Malkin, Jane (1992) Hospital Interior Architecture. New York,
Van Nostrand Reinhold
Miller, R & Swensson E. (1995) New Directions in Hospital
and Healthcare Facility Design. Hong Kong, MacGraw Hill
Nesmith, E.L., Health Care Architecture: Design For The
Future. Rockport Publishes, Massachusetts
Schwarz, B & Brent, Ruth (1999) Aging, Autonomy and
Architecture. Baltimore, The Johns Hopkins University Press.
Pp. 14 –15
The National Association of Swedish Architects (1970) Guide
to construction of social welfare facilities in Sweden during
the nineteen sixties. Stockholm
The Penguin English Dictionary. Penguin Reference Books,
Great Britain
Torrington, Judith (1996) Care Rooms For Older People: A
Briefing and Design Guide. E & FN SPON, London
Vavili, Fani ed. 2001. ‘Design for the Elderly’. UIA-PHG
European Seminar, Volos Greece
Wislocki, Peter “The architecture of the feel-good factor”,
World Architecture No. 47 (June 1996), pp.124-145
Photographs by the writer
Fani Vavili, Dr.Architect, Associate professor, School of
Architecture, Faculty of Technology, Aristotle University of
Thessaloniki, Greece
Address: Al. Michailidi 1, Thessaloniki 54640, Greece
Email: faniva@arch.auth.gr
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
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SHORT CURRICULUM VITAE
Dr. FANI VAVILI - TSINIKA
Architect (A.U.Th), Master of Arts (U.N.London), Dr.
Engineer (A.U.Th.), Associate Professor (A.U.Th.)
university address: Department of Architectural Design and
Architectural Technology, School of Architecture, Faculty of
Technology, Aristotle University of Thessaloniki, 54006,
Greece
private address: Al. Michailidi 1, Thessaloniki, 54640,
Greece
tel. +30 2310 812218, +30 2310 833441, fax. +30 2310
862182, Email: faniva@arch.auth.gr
Dr Fani Vavili- Tsinika is an architect, graduated and
Ph.D. from School of Architecture A.U.Th., Greece, M.A. in
Health Facility Planning, MARU London. An Associate
Professor in the School of Architecture A.U.Th. where she
has been teaching (1976) on several design topics. Since
1979 her work has concentrated primarily on health care
facilities, involving relevant research and designs. She runs
an architectural practice. Her published work has been
presented in several magazines and symposiums and two
books were published recently on designing for the elderly
and for mental health.
Fani Vavili “Guidelines & Health Care Buildings” San Francisco 2003
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