 |
 Introduction
More than 50 years ago, significant medical advances
occurred once or twice a decade, and through the 1940s and '50s,
changes to the healthcare system were based primarily on the growth
of services to support a booming postwar population. The 1960s and
'70s saw increasing breakthroughs in technologies in clinical
fields such as transplantation, microsurgery, and synthetic
antibiotics and also in the fields integral to healthcare delivery
such as communication systems, automated material movement systems,
and systematized infrastructure and building structures (e.g.,
those used at McMaster University Medical Centre in Hamilton,
Ontario).
By the 1980s, major clinical advances came even more rapidly, but
economic recession brought the realization that "bigger, better,
more" could no longer be sustained, and the industry sought methods
to deliver high-quality services more affordably. By the 1990s,
further cost cuts came from reserving inpatient care for the
severely ill and injured, reducing length of inpatient stay, and
promoting outpatient services. Faster advances in medical
technology emerged along with new methodologies and mantras such as
"patient-focused care" (arguably a backlash to the perceived focus
on the bottom line rather than on patient satisfaction),
"multiskilled" staff, and the "paperless medical record."
Today we have an almost incomprehensible list of trends to be
addressed including:
- Continued clinical advances, many tending
toward miniaturization and mobility
- Increased acuity of both inpatients and
ambulatory patients seen in the hospital setting
- Decentralization of services and staff to
patient care units, resulting in multidisciplinary care teams
- Advances in communication/information systems
for patient profiling and charting, for communications between
staff, and between diagnostic services and patient charts
- Increase in minimally invasive procedures,
reducing the need for overnight admission
- Expansion of outpatient clinics and the
creation of ambulatory "themes" through selective clustering
- Increased recognition of the family/caregiver's
contribution to the healing process
- Gradual acceptance of the benefits of
nontraditional modes of therapy such as massage therapy and
acupuncture
- Increased public awareness and access to
information, fueling the consumers' desire for the latest in
diagnostic techniques and treatments
- Increased point-of-care diagnostic testing
- Increased clinical research integrated into
patient care settings
- Increased emphasis on patient (self-) education
in the hospital setting.
Based on the exponential changes in clinical
services, operational trends, and new technologies, it is not
surprising that many facilities, hailed as state-of-the-art 20 or
even 10 years ago, are becoming functionally obsolete long before
their physical life is spent.
As an industry and for most of our individual
careers, we have worked in environments that are the opposite of
flexible. Static building solutions have compromised our abilities
to respond to changes in how we work and deliver services. For
instance, too many solid walls limit our ability to connect
visually and acoustically with our patients and our colleagues.
Floor plans are too narrow to allow for appropriate relationships.
Floor-to-floor heights limit our ability to maintain current
standards for building air handling and electrical systems and to
accommodate some of the new pieces of high-tech equipment. Building
sites do not permit the expansion and renewal that is essential for
today's and tomorrow's healthcare system.
Why Flexibility?
The challenge to all involved in planning, construction, and
management of healthcare facilities is to anticipate, to the
greatest degree, where changes are most likely to happen and to
consider flexibility throughout all stages of the planning, design,
construction, and postoccupancy phases. Incorporating flexibility
into all phases can help to achieve the ultimate goals of client
satisfaction, desirable clinical outcomes, efficient work
environment, and effective use of limited capital dollars.
Flexibility. The term has acquired
motherhood status over the past decade. We're all familiar with its
dictionary definition: "adaptable or variable, not rigid,
responsive to changing conditions." But how can you really ensure
that your healthcare facilities are a sustainable resource in the
face of a rapidly changing and unknown future?
That is the question this article addresses.
We identify some of the critical issues involved throughout the
planning and design processes, provide examples, and outline the
pros and cons of specific approaches to addressing
flexibility.
If we considered the ultimate in flexibility
to be "disposable" buildings and, during planning, assumed a
15-year facility life span (as we might for equipment or hardware),
then we could avoid writing this article. Instead, we assume a
building has a 50-year life span and take the attitude that
buildings are too costly to tear down. Should the driving
motivation be the cost to operate the services rather than the cost
of the building? As you think about that one, we will discuss the
more traditional approaches to flexibility.
The Planning Process
While the capital development process has many aspects, we
have framed our discussion around the following broad phases of
work:
1. Strategic planning
2. Master programming and master planning
3. Functional programming
4. Design development and contract documentation
During each of these phases, planners,
designers, staff, and the facility's decision makers are
responsible for exploring possibilities for flexibility appropriate
to that phase and for clearly directing the subsequent phase. Each
phase has its own set of questions and possibilities for
incorporating strategies for flexibility. If these strategies are
carefully considered during each step of the planning and
documentation of the building, the result will be a dynamic
solution that solves current demands, responds to changing needs,
and welcomes the future for the next generation.
Parallel to any capital planning process is
an operational planning process which, when linked to the facility
planning process, will ensure that the resulting facility
financially supports the organization. This operational planning
will also be the vehicle to identify opportunities to efficiently
deliver and expand services that will maintain the viability of the
institution, consistent with its mission.
1. Flexibility in Strategic
Planning
Hospitals will never be tomorrow exactly what we think
they will be. The corporate strategic plan and mission and vision
statements will define the long-term role of the organization, yet
they must be fluid and changeable. They must anticipate shifts in
program and service delivery. These shifts will result from new
program opportunities, changing demographics, new technologies, new
approaches to service delivery, and other inevitable changes. The
strategic plan should be revisited every few years and adjusted as
appropriate. It is a living document.
Consider the following questions during the
strategic planning phase:
Do we manage our way through changing service demands or design
our way out of them?
Issues such as changing demographics can significantly affect
certain care programs as well as diagnostic and therapeutic
services. Historically, the primary approach to developing
projections has been to straight-line the activity or need
projections (they never seem to plateau!) and, therefore, to
project a forever-increasing need for space. New discussions focus
on whether alternate service delivery approaches might allow the
organization to gradually change how it manages demand, including
alternate approaches to operating the program, allocating staffing,
selecting the array of service providers, and determining how the
facility will be used.
Do current trends create opportunities or
barriers?
For example, consolidating a specialized service with a single
provider or within a single site can create an opportunity to
maintain or develop specialist expertise and attract scarce
specialist resources, but it can also create discord in a community
if the quality of service is not seen as worth the greater distance
to access this service.
Asked another way: Do alternate ways of
clustering services within a facility create opportunities or
limitations in responding to long-range demands and pressures?
For example, will a pediatric strategic plan include pediatric
rehabilitation, or will the rehabilitation strategic plan include
adult and pediatric rehabilitation? Where is the pressure for
flexibility likely to be greater? Is there an alternate service
delivery strategy if experience indicates that the strategy chosen
is not providing the desired outcome?
The range of questions regarding flexibility
will tend to recur in every phase, but the way in which you achieve
flexibility becomes more narrowly defined and more tangible with
each subsequent planning and design phase.
2. Flexibility in Master Programming
and Master Planning
Master programming and master planning is the first
planning phase undertaken toward the realization of a physical
hospital plan. The master program is developed based on the
strategic plan describing programs and services at a high level and
completing basic workload and staffing projections. This
information is used to develop broad-brush estimates of space
requirements for each block of space (i.e., programs, services, or
departments) that will make up the facility. Relationships between
these blocks of space are also documented.
At the same time, detailed information is
gathered regarding the site or possible sites (existing or new) for
development of the facility. Investigations include, among many
elements, adequacy of the site to accommodate the anticipated use;
location relative to the population served; proximity to major
highways for emergency vehicle access; and sufficient size to
ensure that the changes, growth, renewal, and reinvention of the
facility are limited only by imagination, not by real estate.
Other analyses such as soil testing;
topographical analysis; traffic flow patterns; and the capacity of,
and access to, municipal services (i.e., water, power, and
sanitation) must be ascertained and considered adequate for the
present as well as the future. This information, along with the
master program information, helps the architects and planners to
identify the limits and opportunities offered by a site, to develop
master planning massing and construction phasing options, and to
develop preliminary capital cost estimates.
Master planning provides essential
information regarding the current and future expandability and
flexibility requirements of the facility. It is, however, a living
document and will require continual review and updating to make it
useful as a planning guideline.
Consider the following issues in this
phase:
The planning horizon
If we had a crystal ball to see 5, 10, 20 years, and beyond
into the future and to accurately predict medical advances,
changing technologies, and changing practices, we could more easily
project what building changes would be required and incorporate
this knowledge into the master plan. However, most people have
difficulty in thinking much beyond the three- to five-year horizon
and would likely not trust a vision that differs significantly from
the status quo. Therefore, since we are planning for the buildings
to last beyond 30 years, flexibility must be built in to provide
for the growth and expansion of the facility and for changes in
practice.
Single building vs. healthcare
campus
A trend in hospital planning and design has been to view the
concept of hospital as a single-building entity. Facilities of 1.5
million to 2 million square feet are not uncommon. As a result,
floor plates with very large areas have provided significant
opportunities to expand individual departments in response to
changing demands. Conversely, departments located deep within the
floor plates and not adjacent to exterior walls required the
relocation of other departments to accommodate any expansion. This
domino effect increased cost to individual projects and, in some
cases, resulted in cancellation. Alternatively, compromise
solutions physically split the department, resulting in
dysfunctional arrangements and increased operating
costs.
The healthcare campus, not unlike a
university campus, allows for progressive development toward an
ultimate solution. Issues of expansion, adjacency, and
sustainability of the hospital as a whole, as well as the
individual departments, might best be served by a campus approach.
While we assume that our hospital buildings will serve our needs
for 30 years or more, the campus concept allows for continual,
unlimited renewal through the strategic removal of individual
buildings that have outlived their useful life spans. This ability
to selectively renew, replace, and expand individual elements
without compromising the ongoing operation of the entire
organization should be carefully considered. Additional benefits to
the patients and staff concerning accessibility, wayfinding, and
access to daylight, while not specifically flexibility issues, are
opportunities for environments that are scaled to the comfort of
the individual and organized as links to the future.
Provision of support services
Support services such as laundry, food services, and materiel
management can be carried out on-site to meet in-house needs, or
they can be supplied by an off-site commercial enterprise. They
could also be regionalized (i.e., one facility supports all food
production services for hospitals in the area and transports the
finished product). Ideally, regional planning should be completed
before an individual facility develops its master plan, but if
answers are not readily available, planning for in-house
requirements is recommended. While developing the facility's master
plan, the services in question should attempt to locate components
on an outside wall or adjacent to soft space if there is a
potential need for expansion, or they should allow other services
to easily occupy that space if there is a strategy to reduce
on-site support services.
Service growth and change
Central diagnostic services and outpatient services, for example,
are currently high-growth areas, and this trend is expected to
continue. Consider placing these services on an outside wall or
adjacent to soft space such as offices and conference rooms while
specifying that the appropriate building services be provided in
these soft spaces to accommodate future expansion.
Beware of shelled space as a solution. The
decision to shell space in anticipation of future growth may be a
cost-effective solution, but be aware that it could also cause
additional expense to a construction project. Vancouver General
Hospital shelled its inpatient tower based on a 10-year occupancy
plan. Battling major public misunderstanding about why the tower
was empty-and two provincial government elections and funding cuts
later-occupancy of the tower is now five years behind schedule, and
finishing the shelled area now resembles a major renovation project
rather than a simpler interiors finishing project.
As the electronic patient record replaces the
paper record and imaging records are digitized, on-site storage for
paper and films will gradually be replaced by back-up servers.
Consider placing the paper record storage areas adjacent to another
functional area slated for growth.
Building type
Locating space in specific building types, which may attract
different design standards and different unit costs to construct,
is worthy of consideration at the master planning stage.
Major tertiary or quaternary teaching
hospitals are like small cities in that they support large numbers
of people in a wide variety of work environments. They also
accommodate a broad range of space types, as does a city or town,
including commercial space (e.g., offices or medical
offices/practices), industrial space (e.g., materiel management,
engineering and maintenance shops, food production), residential
space (patient and resident bedrooms, bathrooms, living space), and
high-tech space (e.g., diagnostic imaging, clinical and research
laboratories, surgical suite).
Some spaces in a hospital are recognized as
part of a critical cluster that should be disaster-capable, while
most other spaces do not need to be designed to this
capacity.
Vertical vs. horizontal
expansion
The long-term development of the site should be envisioned during
master planning so that options for on-site vertical and horizontal
expansion are identified at the outset. Based on zoning bylaws that
articulate the allowable build-out on the property, defining the
building end point allows the architects and engineers to
appropriately map out parameters that will facilitate future
expansion and flexibility of building use. Establishing future
expansion potentials and initiating the appropriate zoning changes
to accommodate them at the outset ensures that the facility can
achieve its vision within its own control.
The size of the site will, over the long
term, determine the direction for this decision-which, in turn,
will either compromise or be influenced by physical adjacencies,
travel distances, the need to create private vs. public and
semipublic environments, and the need to grow.
Ultimately, a solution that allows for both
vertical and horizontal expansion is desirable, and both provide
opportunities relative to future flexibility. A vertical solution,
as a first phase of development, will preserve the greatest amount
of site area for future needs. Depending on the final solution,
some challenges to the vertical scheme exist: How large are the
resulting floor plates? Can the floors support expansion of large
programs, or do departments expand onto multiple floors? Can a
critical mass of bed numbers and nursing units be achieved, on a
single floor, to allow for "swing" opportunities and changes to
use? How will multiple floor levels link into future horizontal
expansion?
If vertical expansion is envisioned at the
outset of the project, the building's systems can be scoped to
accommodate additional floors at a later date as funding is
available or as workload justifies the expansion. However,
strategies must be established to allow such expansion above
occupied space. Construction disruption, as well as safety to the
occupants and ongoing operations, demands an understanding of how
such vertical expansion can occur.
A horizontal solution, on the other hand,
provides the greatest opportunity to create the departmental
adjacencies that we all desire. Yet this, too, presents challenges
and questions that must be evaluated: Are the floor plates too
large, limiting access to daylight? Are highly technical
departments surrounded by similar departments, thereby limiting
their ability to expand easily or economically? Will future
expansion be a continuation of horizontal elements, creating even
larger floor plates, or will vertical expansion be planned? If
vertical, what provisions have been invested into the original
scheme to ensure the economical achievement of the expansion? What
investments will be lost should the future vertical expansion not
take place?
Understanding the envisioned facility as a
dynamic system and not simply bricks and mortar and understanding
the potential need for expansion beyond the timeline of the current
project will demand a vision that anticipates the design of the
major horizontal and vertical circulation systems (corridors and
core space). Clear, easily extendable circulation routes ensure the
efficient movement of patients, staff, and materials in the short
and long term.
Project phasing
Municipal site services (water, gas, sanitary, and storm sewer
lines) each have origin points on the site. The location of these
entry points may affect the phasing of the construction project and
should be considered in expansion plans. Facility expansion
projects that do not require the reinvention of the infrastructure
are always achieved more easily, at lower cost, and therefore
sooner.
Determining the phasing of the construction
project will allow the appropriate placement of major building
system components such as emergency generators and chillers in
areas that will not require later relocation of this equipment. The
location of air handling systems should also be determined with
expansion in mind because they must remain operational during any
future major renovation or facility expansions. The phasing plan
will also inform decisions regarding the potential capacity of
major mechanical systems so that informed decisions can be made to
create capacity now or to create space for future expansion of
these mechanical systems.
3. Flexibility in Functional
Programming
A functional program is a detailed document that describes the
future functions and operations of a functional area (i.e.,
programs, services, and departments); describes current and
projected workload; identifies the staff complement that supports
the projected workload; and outlines detailed design
considerations, including special design concepts to be
incorporated by the architect, internal and external adjacency
requirements, and a room-by-room space list.
At this stage of planning, the greatest
flexibility needs to reside in the mindset of the project
participants to ensure that the impact of technologies, changes in
practice, and other factors are considered at this point. Ideally,
any operational re-engineering or redesign planning has already
been completed and this information is available to feed into the
functional programming process. If this work has not been done or
is in progress, planning teams should be challenged to explore new
ways of doing things. This is the opportunity to keep processes
that work but to seek better ones if necessary.
Flexibility-related issues in this phase
include the following:
Operational trends
Consultants can provide benchmarking, but staff should also be
up-to-date on the latest operational trends in their area of
expertise, whether it is admission procedures, delivery of nursing
care, clinical management, materiel distribution, communication
systems, patient records management, or food services. New ways of
doing things often can achieve operational efficiencies or promote
client- and family-centered care. Managers and staff should have
informed opinions about the pros and cons of the implementation of
these new processes.
One trend worth consideration is the use of
multiskilled staff, and there are different approaches to achieving
this for different types of staff and in different areas of the
hospital. Multiskilling is generally undertaken to provide
operational flexibility and to create staffing efficiencies. How do
we encourage different ways of working without completely
reinventing the space in which the work is done? Can a flexible
environment incorporate changes in technologies, work arrangements,
and/or numbers of staff without a major reconstruction
project?
Another operational trend is the promotion of
final food preparation close to the inpatient unit. Food is heated
closer to the final destination, and salads and cold plates remain
separate until the moment before serving. This is a client-centered
approach to care; the temperature of the food is better, patients
may have more control over when they eat, and if this also done as
part of a bulk services system, patients can make their main course
choices at the time of meal service. This more decentralized
approach implies that some food service staff functions will move
out of the kitchen and onto the unit, and spaces must be planned on
the units to support these functions (i.e., a serving area and
possibly a patient dining room). If such approaches are considered
to be a potential for the future but not part of the functional
program, spaces that may be converted to these new functions should
be considered and included to ensure the required
flexibility.
A final example relates to the continuum of
care versus clustering of like services: Is all space planned
contiguously for a specific program, or will the outpatient areas
be located with other outpatient services? Continuity of patient
care would be the main advantage to locating a program
contiguously. However, if that program is located on the 11th
floor, would you want to bring outpatients to that area when they
could be better served in a main-floor clinic area? In addition, it
becomes less flexible in terms of the use of space (i.e., clinics
can share spaces) and more expensive operationally because
scattered clinics duplicate services (e.g., waiting, clerical
support, and equipment).
Operational trends must be analyzed carefully
to consider fully the impacts and implications for future
flexibility.
Equipment choices
The location and selection of equipment must be considered.
For example, is the volume of activity in a particular area
sufficient to warrant an ultrasound room there? Alternatively,
portable units may be used and moved to other locations instead of
having all patients go to where the equipment is located;
installation and dismantling costs are also avoided. Considering
this kind of operational flexibility for diagnostic imaging
services will take the pressure off the centralized space as volume
and activity increase in that area.
Service consolidation
Where both adult and pediatric services are being planned, for
example, planning will need to investigate if and what aspects of
these services can be shared in such areas as the ORs, diagnostic
services, and emergency services. Operational efficiencies can be
achieved by sharing some supports. In addition, there is added
flexibility because primary activity may spill over into the
adjacent area if required. For example, if a pediatric operating
room is available, an adult case may be handled in that
room.
Utilization patterns
Some spaces such as clinic space may be shared by
accommodating different clinics on different days. Generic clinic
space is best suited to sharing, but additional storage may be
required if supplies vary widely between clinics or supplementary
rooms are added to house equipment that is specific to one
clinic.
Changes in hours of operation
Changes in operating hours are an option to accommodating
additional workload, but the operating cost implications must be
weighed against the capital cost of more space.
Modularizing or systematizing spaces and
furnishings (establishing a workplace strategy)
Where a variety of programs require like groupings of space, and if
the scale of some programs might change, consider a generic
approach to the spaces, their sizes, and clustering. This allows
the space to work for all such groups and allows the reallocation
of programs within the space over time. Potential applications of
this principle include the following:
- Current experience indicates that inpatient
rehabilitation programs have the same types of space needs as
programs for the multiproblem, medically complex elderly population
(some provinces refer to these patients as "complex continuing
care" or "extended care").
- Can a consistent approach be taken to
developing clusters of ambulatory care facilities so that, while
individual spaces can be furnished or equipped to meet the needs of
a particular specialty group, they also can be modified for
reassignment to other specialty groups at other times?
- Can certain functions be planned in large, open
spaces where modular or system furnishings will allow the space to
be reconfigured in a number of ways? This promotes the reuse of
materials and decreases renovation cost because walls remain
intact.
Data/communication capabilities
It should be assumed that extensive data/communication
capabilities are required throughout the facility-in all offices,
at all patient bedsides, in all conference rooms, in all exam and
procedure rooms, and so forth. This maximizes flexibility in the
use of these spaces. In addition, the type of data input device,
how it is used, and its location must be considered in the
functional programming discussions. Because some areas may have
special requirements, these also should be highlighted for the
architect.
Internal and external adjacency
requirements
Generally, adjacency requirements will have been
determined during the master programming or master planning phase
but should be confirmed during functional programming because there
will still be opportunities to move things around if new
information or ways of thinking highlight the need (i.e., the
master plan must be flexible to consider some immediate changes).
While location and adjacencies must first serve the function of the
component (i.e., program, service, or department), documentation
could also reiterate the need for future expansion and adjacent
"soft space" if required and could also indicate those rooms within
the component that are most likely to require expansion.
Open concept planning
Where applicable, open concept planning should be
highlighted in the design concepts for the architect's
consideration during the design phases. The use of open space that
may be configured in many ways can be promoted in areas such as
labs, offices, and the pharmacy. Modular furniture can be used to
define workspaces, and if walls are necessary, demountable
structures may be used if cost-effective. Standardized service
grids including power and communications, supporting a variety of
configurations, should be considered. This is discussed further in
the section on design below, in the context of building materials
and systems.
Standardization of room sizes
Plans typically recommend that room sizes be standardized
as much as possible. The more that room sizes are tailored to
certain functions, the less flexibility exists. For example, if all
exam rooms are planned at a standard size (e.g., 120 square feet),
the rooms can be used by any clinical service for this function. In
addition, if all offices are planned to be 120 square feet, then
clinic office space could be converted to exam space in the
future.
Flexibility at the patient
bedside
Inclusion of space for flexible bedside use has become
imperative due to the following trends, among others: family
members as caregivers, increased acuity, increased need for
isolation, access to electronic charts at the patient bedside, and
an increase in the number and complexity of mobile equipment for
bedside use.
The universal room concept represents one
means of achieving this flexibility. The universal room has
recently been promoted to increase flexibility in the handling of
patients with the full spectrum of acuity, including telemetry
(Spear 1997). This generic room offers a high degree of
adaptability to changes in demand and use patterns without the need
for remodeling. Each universal room is a private room, and
providing only private rooms promotes patient privacy, maximizes
overall occupancy, and minimizes patient transfers and associated
costs such as tracking records and billing. On the other hand, an
inpatient unit with all-private rooms increases unit size and
staffing costs, and the accommodation of all patient acuities
requires constant staff reassignment. There is also an increased
cost to distribution systems, housekeeping, and other support
services.
The universal room concept may increase
flexibility in an intensive-care or step-down environment, but the
benefits versus the cost to provide such a high degree of
flexibility for general acute care may make this choice
prohibitive. Patient care units of this nature will increase
construction, equipment, and operating costs.
Modular space planning
Considering how different services expand, space
allocations may be based on modules or uniform blocks of space that
may be repeated within a component or constitute a planning unit
that can easily be added later. Labs work well in the module
format, as do general medical and surgical units of uniform numbers
of beds.
4. Flexibility in Design and Construction
Documentation
During schematic design, the client begins to see the facility take
shape. While the space requirements have been laid down in the
functional program, there is still ample opportunity to allow
flexibility in the design itself. The architect, using the
functional program as a guide, creates alternative solutions
(showing the proposed location of each room specified) and works
closely with the users to develop a layout that is both functional
in the present and flexible for future uses.
Flexibility-related issues to consider during
the design and construction documentation phases include the
following:
Departmental/room adjacencies
As identified in previous phases, the concept of locating
individual departments adjacent to "soft" spaces that can absorb
the expansion of "hard" spaces is essential to accommodating the
ongoing needs of the department. Planning for small and continuous
change is as important as the major building expansion project. For
example, the need to increase a diagnostic department by a single
ultrasound machine is a greater and more frequent pressure than the
need to add a new MRI. How can these small but important needs be
met without disrupting the entire program or locating the new
technology remote from the department?
Locating departments that are expected to
experience growth adjacent to exterior walls, along with due
consideration to shafts and mechanical rooms, allows for major
changes in technology and support space. However, for the more
frequent minor changes, other strategies can be used. For example,
a generically sized room will allow a change in functions with
minor alterations. A 120-square-foot office can easily become an
appropriate exam room. Also, a 240-square-foot meeting room, with
minor alterations, becomes two offices or exam rooms.
Building materials and systems
The selection of building materials can profoundly affect
patients' well-being but can also severely limit the facility's
ability to effect change quickly and economically. Detailed
analysis is required to ensure that materials selected for one use
are not too restrictive should the use of the space change. For
example, vinyl and linoleum flooring can serve multiple uses, from
exam rooms to offices to meeting rooms; terrazzo also can serve
many uses provided that coved terrazzo bases are restricted to very
specific areas (the relocation of doors along corridors with coved
terrazzo bases is disruptive, noisy, dusty, and
costly).
Simple materials, used well, will serve the
facility by providing consistent surfaces for maintenance, repair
and change. Wall systems, using standard construction materials and
designed and engineered to provide appropriate acoustical and
visual separation, will dismantle and reconfigure easily when
change is required.
In all hospitals, ceiling space forms the
primary conduit for the distribution of building services.
Mechanical, electrical, and communication systems are most often
delivered to the spaces below through the ceiling space. Ceiling
systems that allow extensive access for both maintenance and change
are essential.
In functional programming, we explore the use
of open spaces and modular furniture, but this can be further
developed during design. For example, furniture systems can enable
rapid reconfiguration of a nursing station and with in-house
maintenance staff-meaning more effective use of the space and the
staff. The addition of new equipment to a space can be addressed.
New ways of working also can be implemented quickly and
economically with little disruption. Such systems have given
hospitals the opportunity to experiment with various spatial
arrangements. Should the experiment not deliver the needed results,
little time and money has been lost.
Structural systems
The establishment of this basic building block must be considered
very carefully. Most obviously, the establishment of the structural
grid or column layout is important to the planning of the spaces. A
grid too small will limit the ability to accommodate large rooms. A
grid too large will tax the building's capital budget. Examples
exist of hospitals that have used the concept of interstitial space
to accommodate a supergrid or large, column-free space with limited
structural limitations on the planning and changes to the floor
plates. The increased capital cost associated with interstitial
space must seem justified to provide an organization with this type
of flexibility.
Space for access and expandability of
building systems is particularly useful above highly technical and
heavily serviced areas such as operating rooms and diagnostic
imaging. In such cases, full-height interstitial spaces may be
considered.
Planning for vertical expansion must be
considered early to ensure that future needs can be accommodated.
Vertical expansion, as mentioned previously, requires specific
plans for its accomplishment and is not limited to simply ensuring
that the foundations and columns can support the loads. A system is
required that plans for the ongoing operation of the occupied
floors below the expansion to protect the occupants during
construction. Once again, the concept of interstitial space can
assist in this regard by separating the construction activity from
the occupied space.
Mechanical, electrical, and
communication systems
These engineering elements constitute the circulatory system of a
building. They are responsible for the maintenance of a comfortable
environment that serves the individual needs of the patients and
staff. These needs will vary dramatically from one area to another.
Issues of air changes for temperature control, infection control,
energy efficiency, safety, and smoke control are some of the key
elements of the mechanical system. Will a system designed to
provide 100 percent outside air provide the facility with the
flexibility to manage its infection control concerns? Will heat
recovery make such a system affordable? Can change be accommodated
on an incremental basis? How much additional capacity should be
built into the system in anticipation of future needs? How might
future needs be met?
Similar questions must be asked and answered for the electrical and
communication systems: How much capacity is required? How much
redundancy should be planned for? How can incremental increases be
accommodated? How will additional cabling be accommodated? Will
"state of the art" today be enough in 15 years? What can we put in
place now to accept changes in technology?
Many more examples of flexibility can be
cited, and this list is limited only by the collective imagination
of the organization and its planning team.
Cost Considerations
Of course, the $64,000 (or $64 million!) question is this: How much
will incorporating all this flexibility cost? Throughout the
process, quantity surveyors or cost consultants must work hand in
hand with the planners and architects to keep the client informed
of the results of their choices. While choosing flexibility over
customization may decrease costs in the long term by facilitating
conversion or expansion of space, overbuilding may be a danger.
Strategies to increase flexibility should be tempered with the
following cost considerations:
- A project phased in over the long term can be
more expensive, as costs increase with each additional construction
phase. Not only is there the cost of planning and designing for
each construction permit, there are also the contractor's
mobilization costs (e.g., crew assembly, insurance, hoarding, and
site servicing) as well as demolition and make-good costs-over and
above the cost of construction itself.
- The indiscriminate use of generically sized
rooms could lead to increased programmed space and increased
construction cost.
- In the long run, operating costs quickly will
far exceed capital costs. Conclusion
In short, the objective of the planning and
design process is to support the efficient and effective use of
space. Incorporating flexibility into the planning of physical
space of the hospital allows for the following:
- Changes in programs provided by the
organization
Changes in how service is delivered
- Operational changes such as new workflow
methods and the reorganization of services as well as staff roles
and responsibilities
- Changes in future workload (increased or
decreased)
Optimum utilization of current or available space
- Sustainable use of an expensive resource-the
hospital facility.
In the ideal world, the perfect balance is
found between functionality of the space and the generic parameters
that afford its flexibility. Staff and patients will enjoy a
pleasant and effective work/care environment. Construction dollars
can be optimized. In the real world, this point of balance may seem
elusive, but teamwork, attention to detail, and open communications
throughout the planning and design process help us close in on our
target. Planning a new healthcare facility
affords an opportunity to create a dynamic and long-term solution
in a manner that will allow the hospital to explore innovative and
exciting ways to deliver healthcare in its community. An
opportunity is provided to create a facility that delivers an
inventive and flexible environment that will accommodate both the
predictable and the unknown changes in a sustainable manner-serving
the organization, its patients and staff, their families, and the
community well into the future.
Bibliography
Hayward, Cynthia. ChiPlanTM A Space Planning
Guide for Healthcare Facilities. Chi Systems Inc., 1995.
Interstitial Space in Health Facilities-A Research Study Report.
Health and Welfare Canada, 1979.
Spear, M. "Current Issues: Designing the Universal Patient Care
Room." Journal of Health Care Design, Vol. IX, 1997.
Strauss, J. J. Facility Planning with Flexibility in Mind.
Proceedings Manual, 1993 International Conference and Exhibition on
Health Facility Planning, Design and Construction, 1993.
Zuckerman, A. M., and C. Hayward. Healthcare 2000-Planning for the
Hospital of the Future. Proceedings Manual, 1993 International
Conference and Exhibition on Health Facility Planning, Design and
Construction, 1993.
|
