H E A L I N G H O S P I T A L Upycling the OLD for a healthier Master Thesis Report by Maria Soledad...
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Master Thesis Report
by
Maria Soledad Larrain Salinas
H E A L I N G H O S P I T A LUpycling the OLD for a healthier NOW
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Master Thesis Proyct by Marìa Soledad Larraìn Salinas
Healing Hospital: Upcycling the old for a healthier now.
Examiner: Michael EdenProfessor: Walter UnterrainerExternal Supervisors: Juri Soolep and Peter Kjaer.
Umeå universitet _ UMA School of ArchitectureLSAP Laboratory for Sustainable Architectural Production Master Program 2010-2012
Thanks to...
My family for all the support during all this time apart and en-couraging me to take risks, travel and believe in my projects,specially when that meant to be apart so far and for so long.
Alice Lindström for her guidance through the very complex sub- ject of health care and believin g in my proposal and the rel-evance of its outcome. And with her to all the staff of MalmöUniversity Hospital and Regionservice Malmö for letting me in-vade their premises and for their valuable time answering myquestions and showing everything, but above all their tremen-
dous disposition to help me.
To my teachers for their advice on assuming this subject andallowing me to see it through.
To my classmates for opening my world to so many cultures,and giving me the chance to experience so many different lan-guages, food and places, and above all for making me want togo to all those places afterwards and visit.
To my swedish friends for always asking me: why did I came sofar away to the dark and eternal winter? Which let me appreci-ate what Sweden is and take as much as I can of this experi-ence.
To my chilean friends in Sweden, for their unconditional pres-ence and being my family away from home.
To UMA School of Architecture for creating a great space to cre-ate and propose, and letting me be part of it.
And to everyone that was part of this great experience.
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CONTENT
PART 1 : RESEARCHTHESIS STATEMENT 8
MOTIVATION 10
HEALTHCARE 12
Health: What is and How to Achieve it? 14
Healthcare through time 18
The Hospital now 24
THE HEALING ENVIRONMENT 28
What to take into account 30
Factors and effects 34
Evidence Based Design 42
PART 2 : MALMO UNIVERSITY HOSPITALHISTORY AND CONTEXT 46
VISION 48
ANALYSIS AND MAPPING 50
STRATEGY AND MASTERPLAN 52
BUILDING 65 54
NEW PROPOSED BUILDING 62
CONCLUSIONS 76
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The urban migration is expanding cities in an extreme way, to avoid
these we have to re conquer and re use our city centres and nd a new way
to inhabit them.
We have to start recycling more than plastic. Our attitude toward re
using has to go further than a fashionable thing, to a social strategy. The aim
is to implement this attitude into one of the most important engines of the
city, where great impact can be achieved: the hospital.
By getting involved and assuming a propositional attitude, the idea is
to demonstrate that not only we can re use resources but also you can create
better realities, by rethinking health and what is being healthy.
MOTIVATION
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What is health?The World Health Organisation (WHO) dened health in
1948 as ‘a state of complete physical, mental and social well-
being and not merely the absence of disease or inrmity’.1 This
coincides closely with the holistic view seeing the patient rst as
a person within their family, community and workplace, and rec-
ognising the positive and negative inuences each can have on
the person. Helping an ill person back to better health requires
due account to be taken of factors other than their physiology
and anatomy; meeting psychological, social, spiritual and envi-
ronmental needs are important.
1 World Health Organization. 2006. Constitution of the World Health Or-
ganization - Basic Documents, Forty-fth edition, Supplement, October 2006.
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If we take the matter in a simple way, hospitals are the
institutions that implement society’s health care, but we start
with a void: what is health care? Who are we caring for? And
what should they care about?
When people is asked about the role of a hospital, in the
majority of cases the concept: take care of the sick, comes up.
But when asked what is health and being healthy, more choices
come to mind. Health as a more general understanding is not
just a state, but also “a resource for everyday life, not the ob-
jective of living. Health is a positive concept emphasizing social
and personal resources, as well as physical capacities.” 1
As the early word comes from a less medical root, hospi-
tal per se comes from the sense of hosting, where there are two
actors in a dynamic relation: the host and the guest, each hav-
ing its role. The concept of hospitality is born as offering comfort
and guidance to strangers, which during time has been lost in
the hospital duty and responsibility. Is here where information,
but specially trust come into place, two concepts that are natu-
rally there but should be implemented and strengthened. As
was mentioned health is a double relationship, where we get
cared for when in sickness, but there is much more to do before.
Our health is bounded to external factors such as genetic and
environmental agents. From our transport system to our politic
1 World Health Organization. 1986. Ottawa Charter for Health Promotion,
adopted at the First International Conference on Health Promotion, Ottawa, 21 No-
vember 1986 - WHO/HPR/HEP/95.1.
mid-13c., “shelter for the
needy,” from O.Fr. hospital, ospital
“hostel” (Mod.Fr. hôpital), from L.L.
hospitale “guest-house, inn,” neuter of
Latin adjective hospitalis “of a guest or
host,” from hospes (gen. hospitis); see
host (1). Later “charitable institution to
house and maintain the needy” (early
15c.); sense of “institution for sick
people” is rst recorded 1540s.
http://www.etymonline.com/
index.php?term=hospital
Sjuk hus = Building of the
sick, comes from the middle High Ger-
man siecen-hûs, which was designated
a hospital for lepers.
(New Hospital Buildings in Ger-
many, page 12)
19%20%
51%
10%
B I O
- G E N E
TIC F A C
T O R S
C O M M U N
I T Y I N
F L U E
NCES AN D S O C I A
L S U P O R T
A C C E
S S T O
H EA L TH C AR E S E R V I C
E S
L I V I N G
A N D W
OR KING C O N D I T I O N S
S O C I O
- E C O
N O M
I C, C U
L T U R AL, ENV I R O N M E N T A L C O
N D I T
I O N S
+HEALTH
-HEALTH
ELEVATED
LEVEL OF
WELLBEING
AND PER-
FORMANCE
CAPACITY
PREMATURE
AND PRE-
VENTABLE
SICKNESS
AND DEATH
WE L L BE I N G
S
I C K N E S S
strategies and agricultural legislation, all actions impact on the
nal personal health.
Actually today some of the diseases that are affecting
a majority of the populations and collapsing our health system
come from unhealthy and uninformed behavioural choices in a
daily basis. According to WHO (World Health Organization) in
their 2009 Report, “Global health risks: mortality and burden
of disease attributable to selected major risks”, the risk factors
on high-income countries are directly linked to non intelligent
choice of life style and lack of health education, such as: to-
bacco use and high blood pressure, more than to environmental
factors, such as water pollution and sanitation infrastructure.
As a matter of fact the most important factor that will
determine our health is life style. Over a 50% of our health con-
dition will be guided by our life choices in matters like: eating,
exercising, sleeping, smoking and relaxing2. Many of this items
are not seen as very inuential in ones life, but more and more
is been proven that on a medium/long term, simple things like
exercising constantly will have a bigger impact in someone’s
future condition than treating the resulting disease afterwards.
Though many factors seem further than our personal
range, it’s important to realize how health is a joint cause and
every actor involved has it own role to play, from local gov-
ernment to social institutions. Health as we know is not just
about not being sick, but a whole range of other aspects, that
is why today health care is not seen just like a hospital, but a
dynamic network, wived into the urban fabric. The hospital till
now appeared as the safety net of the system, when nothing
else worked, but latest trends involve the hospital’s mission with
broader issues than just treatment.
In a broad look there is a clear process that guides
healthcare, and will in an end point guide the planning of a
hospital. We can identify ve very distinct stages where society,
or in this case the patient, move through. Its important to un-
derstand that though the different stages are always present in
2 McGinnis, J. M. and Foege, W.H. (1993). “Actual Causes of Death in the
United States,” Journal of the American Medical Association, Volume 270, Number
18: 2207-2212
HEALTHCARE:What it is and How to achieve it.
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PREVENTION DETECTION DIAGNOSE TREATMENT END OF LIFE
the health care system, some times the focus is invested in some of them instead than over the
whole cycle.
Prevent: This is the stepping stone of the system, cause this sometimes simple action
translates in further benets for the whole system. Simple actions like: physical tness, bed nets
against malaria, a good diet, clean drinking water, less use of tobacco, etc. Preventive action is
taken sometimes as a quite personal matter, but for it to have a real impact in the overall system
is necessary that is reinforced with social initiatives, such as proactive prevention of future ill-
ness. The whole point is in the line of a popular saying: “there is no better patient than the one
that is not sick”.
Detect: Nowadays the healthcare system helps who comes with a condition, and some-
times in that situation is already late, that is why proactive outreach on the part of the healthcare
system is important. Monitoring and detecting conditions in early times is not only efcient for the
system, but also benecial for the patient. This strategy must be impulsed by the health institu-tions and also governmental campaigns, focusing and spotting beh avioural and medical trends in
the community, so they can be addressed before a condition becomes a disease.
Diagnose: This is probably today’s one of the key processes in a hospital performance.
An on time and efcient diagnose is probably one of the most cost effective steps, where health
management can improve their performance. For the organization is a way to save resources
and time, which translates in the possibility of relocating those resources where they are really
needed. A miss diagnose can waste a lot of time and human workforce, but the most relevant is
also that the timeline of a diagnosis is critical for many disease paths.
Treat: This is the core of health care’s mission today and through time, though this is a
very technical and specic process, it is the reason for why people resort to the health system.
Though curing is important, caring has become a side concept, expanding the technical trea tment
to a more complete view of recovery.
End life: Probably one of the most controversial stages in healthcare, has to do with giving
life quality to whom is about to die. In difference as the other processes, this does not require of
specialist of different areas, but a more holistic approach that give relief and a good end periodof life for people in that path. Is not about effective endless treatment trying to x something
broken, but to reect on the general state of the patient and what is better for their case. For ex-
ample there is no point to do a high risk operation to x one organ on an old patient who’s entire
system is shutting down, but to improve its environment.
THE DETERMINANTS OF HEALTH
Many factors combine together to affect the health of individuals and communities.Whether people are healthy or not, is determined by their circumstances and environment.To a large extent, factors such as where we live, the state of our environment, genetics, ourincome and education level, and our relationships with friends and family all have consider-able impacts on health, whereas the more commonly considered factors such as access anduse of health care services often have less of an impact. The determinants of health include:
the social and economic environment, the physical environment, and the person’s individualcharacteristics and behaviours.The context of people’s lives determine their health, and so blaming individuals for
having poor health or crediting them for good health is inappropriate. Individuals are unlikelyto be able to directly control many of the determinants of health. These determinants—orthings that make people healthy or not—include the above factors, and many others:
Income and social status - higher income and social status are linked to betterhealth. The greater the gap between the richest and poorest people, the greater the differ-ences in health.
Education – low education levels are linked with poor health, more stress and lowerself-condence.
Physical environment – safe water and clean air, healthy workplaces, safe houses,communities and roads all contribute to good health.
Employment and working conditions – people in employment are healthier, par-ticularly those who have more control over their working conditions
Social support networks – greater support from families, friends and communitiesis linked to better health. Culture - customs and traditions, and the beliefs of the family andcommunity all affect health.
Genetics - inheritance plays a part in determining life span, healthiness and the likeli-hood of developing certain illnesses.
Personal behaviour and coping skills – balanced eating, keeping active, smoking,
drinking, and how we deal with life’s stresses and challenges all affect health.Health services - access and use of services that prevent and treat disease inuenceshealth
Gender - Men and women suffer from different types of diseases at different ages.
World Health Organization _ Health Impact Assesment
http://www.who.int
Five main processes in healthcare:a citizen perspective; Bo Bergman, Duncan Neuhauser, Lloyd Provost. Downloaded from qualitysafety.bmj.com on February 28,
2012 - Published by group.bmj.com
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Hospitals have come a long way through history, not
only in a formal point of view, but most important in their
genesis. They have been a kind of reection on society
all along, because the denition of health and health care
goes deeply rooted to what is the concept of person and
society. To understand where is the debate now, and why
has it got here, we need rst to understand the journey of
this institution, that through the centuries has been evolv-
ing looking for the right way.
Some of the earliest documented institutions aiming
to provide cures were ancient Egyptian and Greek temples.
In ancient Greece, they were dedicated to the healer-god
Asclepius, known as Asclepieia. This temples presentedthemselves as centres of medical advice, prognosis, and
healing1. At these shrines, patients would enter a dream-
1 Risse, G.B. Mending bodies, saving souls: a his-
tory of hospitals. Oxford University Press, 1990. p. 56
like state of induced sleep, in which they either received
guidance from the deity in a dream or were cured by sur-
gery. The worship of this god and the treatment rituals
were kept by the Romans.
After Romans converted to Christianity, health cov-
erage expanded through the empire. Following First Coun-
cil of Nicaea in 325 A.D. construction of a hospital in every
cathedral town was begun. Among the earliest were those
built by the physician Saint Sampson in Constantinople and
by Basil, bishop of Caesarea in modern-day Turkey. Called
the “Basilias”, the latter resembled a city and included hous-
ing for doctors and nurses and separate buildings for vari-
ous classes of patients, with a separate section for lepers.2
Some hospitals maintained libraries and training programs,
and doctors compiled their medical and pharmacological
studies in manuscripts. Thus in-patient medical care in the
sense of what we today consider a hospital, was an inven-
tion driven by Christian mercy and Byzantine innovation.
Byzantine hospital staff included the Chief Physician (ar-
chiatroi), professional nurses (hypourgoi) and the orderlies
(hyperetai). It can be said, however, that the modern con-
cept of a hospital dates from AD 331 when Constantine ,
having been converted to Christianity , abolished all pagan
hospitals and thus created the opportunity for a new start.
Until that time disease had isolated the sufferer from the
community. By the twelfth century, Constantinople had two
2 Catholic Encyclopedia - [1] (2009) Accessed April
2011.
Temple of Asclepios, Greece-600
Temple of Asclepios, Rome-293
Medirigiriya Hospital, Sri Lanka-400
Valetudinarium Hospital, Rome-100
Saint Basil the Great, Cappadocia369
Gundishapur’s Academy, Persia271
Xenodochium of Mérida, Spain580
Abbey of Saint Gall, Switzerland612
Hôtel-Dieu, of Paris, France651
Santo Spirito in Saxia, Italy1204
100 200
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well-organized hospitals, staffed by doctors who were both
male and female. Facilities included systematic treatment
procedures and specialized wards for various diseases. The
Christian tradition emphasized the close relationship of the
sufferer to his fellow man, upon whom rested the obliga-
tion for care. Illness thus became a matter for the Christian
church.3
Medieval hospitals in Europe followed a similar pat-
tern. They were religious communities, with care provided
by monks and nuns. Some were attached to monasteries;
others were independent and had their own endowments,
usually of property, which provided income for their sup-
port. Some hospitals were multi-functional while others
were founded for specic purposes such as leper hospitals,
or as refuges for the poor, or for pilgrims: not all cared for
the sick.
In Europe the medieval concept of Christian care
evolved during the sixteenth and seventeenth centuries
into a secular one. It was in the eighteenth century that
the modern hospital began to appear, serving only medical
needs and staffed with physicians and surgeons. The bour-
geoisie started founding the new hospitals i n the fast grow-
ing cities. Now they were civic buildings, commissioned by
authorities , but usually managed by religious orders. Hos-
pital became the face of reason, of progress. Though the
world was still runned by aristocracy and the church, the
3 http://www.edwardtbabinski.us/history/hospital_
history.html
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hospital became an island for the rational thinking and a
symbol of what was coming after, started by the french
revolution in 1789.
A stepping stone was in 1772 when a big re burned
the Hotel Dieu in Paris, in icon of healthcare of the times.
After this event, there was an opportunity to re-think and
propose new environments for the sick. Even though noth-
ing was built right away, it fuelled the discussion, shifting
the healthcare aims of the time. Now it wasn’t a place
where to accommodate poor and sick people, but to take
care of the “common man”. By 1859 Florence Nightingale,
an Italian nurse with high knowledge on health statistics,
noticed that the death rate in city hospitals was much
higher than the patients in a same state treated outside
this institutions. This became a turning point on the ob-
jectives of hospitals of th ose days. The urbanity of the
time was faced with a mayor issue: hygiene, and hospitals
turned in search of clean air. This quest became the rst
step towards natural environment, and relating nature to
the healing process.
Though the popularity of the pavilion type grew, the
importance of nature took a step to the side and medical
advances took over. Now the pavilion model was a repre-
sentation of medical specialization, a series of small hospi-
tals inside the original one.
Everything changes by 1895, when Röntgen, a
German physicist discovered and shared the X-Rays. Now
health care was not so much about the care, but instead,
technology took its place. With this turnaround now hos-
Hospital San Pau, Barcelona '
Hospital leeuwenberghkerk, Royal Hospital Chelsea, UK Hospital Charite, Berlin Hotel Dieu, Paris. .
Hospital of Jesús Nazareno, Mexico
Vienna General Hospital, Austria7 4
Selimiye Barracks, Turkey
Lariboisière Hospital, Paris
St Thomas Hospital, London, UK.
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pitals became full of new equipment, and with that the
services provided became out of reach for the poorest and
needy, which till now was its objective crowd. Hospitals
came from almshouses to top medical institutions, chang-
ing the aim from helping the ones in need to developing
technology. The pavilion system showed to be inefcient
with the long distances and communication issues, and the
expensive machinery forced to go back to concentration
of resources. Now doctors, machines and the elite where
the inhabitants of the new hospital: the Block Hospital.
Highly concentrated and big scale representative build-
ing conquered the city. This monumental creature lost the
feature and ambition to create healing environments that
would emulate nature. This machine like buildings accom-
modated technology and resources in a efcient and cost
effective way. Nature and small scale movement became
an artistic ideal.
This shift lead to over organized, technology ridden,
anti-human establishment, mostly blamed to the modern-
ist architecture. Though during the 20’s and 30’s avant-
garde modern movement shared the nature-oriented view
of the beginning of the century, but didn’t got the chance
of taking those ideals to reality.
“No art is more widely misunderstood than the art
of achitecture, and no buildingd illustrates teh misunder-
standing more clearly than the hospital. The hospital has
become completely a product of the technologies of medi-
cine and of manufacture, so precisely adapted to the uses
of sciences, as to become in effect a scientic instrument
not escentially different from the X-ray machine or the op-
erating table which it encloses. It is hard for people to
imagine any relationship between such a building and taht
great tradition whose owers are the Parthenon and the
Cathedral of Chartres. It is hard to think of a hospital as a
work of art”
J. Hudnut, ‘Architecture and the Art of Medicine’, in Journal of the
American Institute of Architects, 1947, n°4, 147.
After the Second World War, and due to the social
revolution that came with it, the “welfare state” concept,
shook things for hospitals again. The late examples of
technological sanctuaries had to open way back to the “
common man” and safeguard its health. The hospital re-
gained its role as a social institution, and became a monu-
ment for welfare, and entering a new age of science pro-
gress as social justice.
This new capitalistic oriented welfare found its face
in the international style, which introduces back the refer-
ence to nature, taking this urban institution to the outsides
of cities in the search of spacious locations. The architec-
ture became synthetic, a combination of three parts and
characters: Patient ward, Medical Treatment, Daycare.
This became a grouping exercise and a typology test for
architects, resulting in during the 50’ and 60’ in several
types named after the letter they resembled: T, K, L, H.
During this time medical technology and science
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where moving faster than the have ever done it before,
and it was precisely this that became the biggest challenge
for architects and hospitals. Adaptability became an essen-
tial design aspect to keep up with the dynamic scene of
technology. As a result of building experience during 50’s
and 60’ American Military Hospitals came with a strategy
for this changes. Most of the technological changes would
occur in the treatment and outpatients area, so for this
they would have a low horizontal building, easier to retrot
and redesign, and the patient wards that was the area with
less change could be concentrated in a high rise building.
This was a building boom for hospitals, especially in Eu-
rope and the United States, where this new slick and high
tech building took place, again an example of rationality,
but this time was seen in another way.
A counter culture, instead dened it as a bureau-
cratic creature that represented the political and economi-
cal establishment. The hospital became a bureaucratic
sphere, governed by politics or big companies, and this
inuenced the inner life of it. Patients were not treated like
a person anymore but like a “disease case”, and it could
say that the patient concept almost disappeared from the
hospitals concerns. The modern life was blamed to be the
source of illness, society as a whole was seen as sick and
the ‘medical fortress’ was an accomplice. This views turned
the scene around, where society had to shift from institu-
tional power to citizen power, and this had a huge impact
inside the hospital, where patients became the main actor
in the new system: patient-centered care.
This new shift pointed to a more natural society,
giving the importance of the physical and social environ-
ment for the well-being of people. So the challenge of the
new hospitals now was quite different: it was a balance
play between the individual and the collective; the per-
sonal experience of the patient and the medical needs of
the staff. The answer for this new approach was the instal-
lation of basic, industrially built structure that would work
as a neutral framework where more individualized com-
ponents could be inserted, tackling the core of the hos-
pital’s problematics. This “style” also had other concerns,
beyond only the hospital building itself, but its urban role.
Stepping away from the monumental big scale building,
there’s mostly low rise buildings. This new projects try to
read the large scale grid, and integrate to the urban tis-
sue. The hospital grid tries to follow the surrounding city,
becoming unrecognizable as a single building or institu-
tion. The strategy is to develop really exible structure,
for the same reason they must be neutral and inexpres-
sive, the function of today won’t be the same as tomorrow,
so the frame shouldn’t express neither. Another turn was
the differentiation of the medical machine and the ows
of visitors and patients, during the 80’ and 90’ hospitals
where recognized by large halls and passageways, cov-
ered street and squares. This is the time where shops and
urbanity jump inside the hospital structure, accompanied
by change in the management vision, the hospital became
more a social place than a medical one. But this attempt
to take part of city urban life, wasn’t completely accom-
Hospital San Pau, BarcelonaLluis Domenech i Montaner1902
Paimio Sanatorium, FinlandAlvar Aalto1929
Beaujon Hospital, FrancePlousey, Cassan, Walter1933
Maimonide Hospital, Sn Fco, USAErich Mendelsohn1946
Princess Margaret Hospital, UKPowell, Moya
1957
Vienna General Hospital, Austria1784
Univ. Medical Center, Groningen, NLUMCG1997
St. Mary’s Hospital, Newport UKAhrends, Burton, Koralek1982
Erasmus Hospital, Rotterdam, NLMedicine Faculty Rotterdam1972
100 200
1 9 3 0
1 9 3 0
1 9 4 0
1 9 5 0
1 9 2 0
1 9 2 0
1 9 6 0
1 9 7 0
1 9 8 0
1 9 9 0
2 0 0 0
2 0 1 0 P
a v i l l i o n H o s p i t a l
A r t N o u v e a u
M o d e r
n i s m
M o n u m
e n t a l
F u n c t i o n a l i s m
H e a l t h
S u b u r b
H o s p i t
a l C i t y
C i t y i n
t h e C i t y
T h e i n n e r S t r e e t
E n e r g y I s s u e
_ X
R a y s
plished, though shopping and social activities where under
the same frame, this were very different from the medi-
cal side, now the border was inside the hospital ground,
instead of actually blurring the limits it was just a matter
of disguise.
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24 25
After studying the journey of this emblematic institution
the only thing that can be seen as permanent has been the
continual change, not only in shape and strategies, but in its
core. Because of this continuous shifts it feels sometimes that
hospitals are, one step behind or are just a bit too late to meet
current needs of society. That maybe is because a hospital pro-
ject is planned to be long term, taking into account that the life
cycle of one of this structures is of 50 years. Lately, as most
technical areas, has been growing and changing at much higher
rates than ever, leaving us with a complex scenario.
The hospital as a building has been adapti ng to time, but
without a complete solution. We can go back to the beginnings
of the modern hospital in the enlightenment, where rationality
ruled the guidelines and nature had an important healing role,
but the patient was not the focus, but its illness. After, moder-
nity creates the most efcient hospitals, but falling into the trap
of giving life to a machine, more focused on its functioning that
what this engine was producing. Then we come to today, due
to high regulation and the current bureaucratic apparatus, hos-
pitals have been victims of lack of planning and power games,
becoming complex messy buildings instead of better buildings.
The System itself is portrait in this kind of patchwork inside
the institution, building from different times without any main
guide, just stacked together as the needs appear. Creating in-
timidating fortresses lled with a riddle of corridor mazes runby bureaucracy. This anonymous institutional complexes are
hardly ever functional, and most of the time are unt for its
purpose, resulting in high factors of stress and anxiety, which
undermines the patient’s recovery. This scenario is the result of
an reactionary attitude toward health and well being, leaving
the big pictured blurred for anyone to see, guiding blind throw
contingency.
“Hospital mirror and project the consciousness and
acceptance of responsibility of its society” The Zitgeist
EDUCATIONAL
CAMPAIGN
NATIONAL
POLICIES
COMMUNAL
PROGRAMS
SOCIAL
INICIATIVES
REGIONAL
POLICIES
WELLNESS
INFRASTRUCTURE
FOOD
INDUSTRY
TRANSPORT
SYSTEM
W H A T
TO DO?
HIGH TECHHOSPITAL
GREEN
HOSPITAL
HOLISTIC
HOSPITAL
CLIMATE
FRIENDLY
HOSPITAL
FREE MARKET
HOSPITAL
WELLNESS
HOSPITAL
ENERGY
EFFICIENT
HOSPITAL
COMMUNITY
HOSPITAL
WHER E
TO NOW?
OUTSIDE THE CITY LOWNING THE CITY L ALIEN IN THE CITYL BECOME THE CITY
THE HOSPITAL NOW:The New Mission and Challenges of Today.
Hospital and the City
Today Hospitals face again a turning point, where not
only the building is being questioned but the system at large.
More and more, the view of the hospital as a city has come
through, and the will to integrate to the urban tissue is dominat-
ing, but what does this aim to? Is not about systems and repli-
cating a model, it goes beyond that. The ultimate characteristic
that comes out from a good design city and what is lacking in
the healthcare area is integration that is a direct result from a
living and active community. Which will translate in to a social
engine that will create a true platform for social, economic and
cultural integration, because health has never been an individual
matter but a social one, and for that it has to be understood aspart of a bigger picture. Is mistakenly believed that if a hospital
is located in an urban setting, this will be a guarantee for its
integration, but this is a complete error, consequence of the lack
of understanding of the complexity of the health landscape. The
aim of re-urbanizing hospitals is not only so they t in the ci ty
on a functional way, but also to has to overcome built obstacles
and nally connect physically to the city. One example of this
is the University Medical Center Groningen, where even though
is on a urban location its surrounded by built barriers and the
only place that opens up, is in a monumental entrance hall with
a “public plaza” towards a highway instead than the city itself.
Industrialized Hospital
One criticism often voiced is the ‘industrialised’ nature
of care, heritage of the machine hospital of the modernists stillalive to this times. The high working pressures often put on the
staff can sometimes exacerbate such rushed and impersonal
treatment. The architecture and setup of modern hospitals of-
ten is voiced as a contributing factor to the feelings of face-
less treatment many people complain about. The high stress in
health workers, not only affects their work and health but also
contributes to the already stressful experience of the patient.
According to a report about Work life and Health in Sweden
done by the National Institute for Working Life almost 40% of
the health workforce is under an “unhealthy” work situation. In
addition to that, most of budget cut in health are solve by per-
sonnel reduction, that not only puts more work and responsibil-
ity onto one person, but also creates the ghost of uncertainty
of work. All that comes to the most serious matter how it is
mental health.
In Sweden from the 90’ sickness absence and disability
retirement caused by mental problems and disorders have risen
markedly. Concepts such as burnout, depression and chronic
fatigue syndrome have been used increasingly in the media and
are now part of everyday language.
These phenomena are probably the result of prolonged
stress processes, and the biological and medical risks of pro-
longed stress have been highlighted recently (Lundberg & Wen-
tz 2004). Signs of reduced mental well being therefore deserve
attention, since they may develop into serious health risks inthe long term.1
Green Hospital
As time goes “Green” approaches have appear in every
area and hospitals are no exception. Though is very true that
certication and regulation helps keeping matters in order, and
is a visible way for institutions to show their investments and
standards to the community their serving, and in that way gain
its trust.
Until the mid 90’s hospitals and health care facilities en-
joyed a deceiving reputation the cleanest buildings, where peo-
ple didn’t question their neatness, but after an eye opener re-
port issued by the US Environmental Protection Agency, where
medical waste incinerator, over 5.000 in North America, turned
the red alarm becoming the single biggest source of dioxin emis-sions into the atmosphere. With this all heath institutions where
put on the spotlight, and their attitude towards environmental
policies and strategies had to change from a quite passive one,
to a more active one, giving the industry the chance to lead the
needed change.
Hospital are not only expensive, but also high ly polluting
and stress producers.
Today the Healthcare sector is growing fast, and many
eyes are on it for its big impact, not only social, but also eco-
nomical, political and ecological. Now is the time where we
1 Worklife and Health in Sweden 2004. Rolf Å Gustafsson,Ingvar Lundberg
(eds.)
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Hospitals in the US have “enormous carbon
footprints”, being the second most energy intensive
building type behind that of the food service indus-
try and twice that of commercial buildings.
They are “extraordinarily water intensive”,
averaging about 300 gallons per patient per bed per
day when there is a desperate need to reduce the
water footprint.
The National Health Service (NHS) in Eng-
land has calculated its carbon footprint at more
than 18 million tons of CO2 each year — 25% oftotal public sector emissions.
Brazilian hospitals use huge amounts of en-
ergy, accounting for more than 10 % of the coun-
try’s total commercial energy consumption.
Towards a Green Hospital
Speech held by Dr. Wolfgang Sittel at the Asia Pacic-
Weeks in Berlin.
September 8ht 2011.
GOVERNMENT MANAGMENT
DOCTORS
NURSESPATIENTS
INSURANCE
COMPANY
CURRENT PURPOSESFOLLOWED BY HEALTH CARESECTOR:
Enhance communica-tion between referring phy-sicians and the hospital, im-prove team communications,streamline patient ow, anddecrease waiting time andoverall length of stay.
HEALTHY
PERSON
HEALTHY
HOSPITAL
HEALTHY
CITY
HEALTHY
HOUSEHOLD
EDUCATION
+
have to realize that they are part of an ecosystem, and so are all
human creations. Its being proven that our wellbeing is directly
related to our environment, and for that we are not only linked
to the ecosystem around us, but part of it. This means that our
well being is directly related to the environments well bein g, and
you can’t have one without the other.
A hospital or any health institution can see that they
can no longer think of themselves as an isolated island, exempt
from its urban ecological context. We have come to a pointwere healing the individual is directly connected to healing our
planet. I might sound a bit to general or heroic, but no society
will ever have healthy individuals, healthy families or healthy
communities if there is no clean air, clean water and healthy
soil.
Health care institutions should not build to meet a label,
since they will change with time, but use the existing resources
and make it efcient. The existing health infrastructure is there
and is huge, the impact on the overall system, if they would be
used, upgraded and renovated with a long term vision, it would
be more efcient that burying them and build new. The value of
the existing structures is great, not only for its cost and mate-
rial, but for its location and existing relation with the city.
Hospital as a Social entity
Hospitals are today barely alive and serving its purpose:
healing sick people, though the purpose also has to change. Is
being sick wasn’t bad enough, patients are obliged to go to this
intimidating place where they are stripped of any privacy, suffer
of long waiting times, are exposed to uncontrollable noise and
get separated from family, taking into account that from the
start people in a hospital are already l ow in spirit hospitals today
only manages to get that spirit even lower, not only for patient
but also for the a lready overwhelmed staff.
Hospital staff is mostly disregarded in the discussions
and are seen as a pressure group, difcult to negotiate with,
but they are the direct link between the “machine” and the pa-
tient, they are the face of the system and the change starts
with them. Nurses and doctors have the opportunity to touch
peoples life, making them important agents for changing think-
ing, behaviour, communities and patterns. The importance is to
not forget that Health care is health+care and that show be the
guide line for every decision and action.
Now they are work as Medial Health Centres for the In-
dividual, but they must take the leading step towards the para-
digm shift: Heath is not individual but collective. The challenge
for hospitals is to walk away from just being a building but a
leader of change and education, which is also the key in the
prevention of disease.
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H
Heal:
‘To restore to health’
‘To cause an undesirable condition to be
overcome’
T H E H E A L I N GE N V I R O N M E N T
Upycling the OLD for a healthier NOW
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It is been a couple of decades now that hospitals have
been criticized for its poor spatial qualities and disregard to-
wards the patient, who is supposed to be in the genesis of it
core. And how it always works, if something gets criticized pro-
posals have to be suggested, is in this dynamic that the concept
of healing environment was created. But this shouldn’t be taken
lightly, because as its name says: the environment has to heal.
But how do we know that? For that a method is needed.
Healing environment: describes a physical setting
and organisational culture that supports patients and families
through the stresses imposed by illness, hospitalization, medi-cal visits, the process of healing, and sometimes, bereavement.
During the second half of the last centu ry, medicine took
a scientic turn, in hand with evidence based medicine, the
whole eld moved towards research, which is by the way today,
one of the biggest areas in the medical community not only
for it reputation but also because is highly nanced, from that
hospitals couldn’t function without a research branch in their
system.
After World War II not only medicine was advancing in
the research eld, but from the contingency of the time envi -
ronmental psychology stepped up, raising new discoveries but
also new questions. Is during the 80’ when the architect and
researcher Roger Ulrich saw in this investigation a rich source
of data, through a report exposing that surgery patients witha view of nature suffered fewer complications, used less pain
medication, and were discharged sooner than those with a
brick-wall view, and with this the effects on people of a certain
environment started to be measured.
Rooting from this scientic approach the hospital’s critics
had something to work from, and now evidence could support
decisions not only in the eld of architecture, but also designers
and managers. Everything started to be measured: clinical out-
comes, staff efciency and patients impression; since this was
an empirical approach, replacing philosophical matters, opin-
ions and suggestions weren’t regarded because of their lack of
objectivity, instead only “rst reactions” were used as rm data,
PATIENT:-Need of privacy
-Need to socialize with
others
-Healing Environment;
Indoor+Outdoor
STAFF:-Need accessibility tocorridors and rooms-Comfortable Workingenvironment-View to outside/ Relation to timeand space
“John gets home at 6 am. Takes the grocery list from his
wife who’s leaving for work. He has to dress his son that also
got a cold thanks to the germs he brings home, he hates night
shifts. He drops his son off, does his groceries and tries to catch
a few hours of sleep. Even after all the years he hasn’t managed
to adjust to the shift. Wakes up in time to make dinner and fetch
his son from school. He waits for his wife and hopes she comes
in time or he will have to leave his son at the neighbours. She
comes. They exchange a few words and off he goes. He will
be going straight to the hospital from her elderly home for yet
another night shift.
VISITOR:
-Smell of hospital -Walking through the
corridors -Comfortable place to
relate to the patient
“Bob can meet his mother from 10 to 1 o’clock, then
his mother goes to lunch. Then he’s able to see her from 3
to 7 in the evening. After work goes to the shop to buy some
things for his mother and goes to the hospital, already being
around 5. He can meet a lot of visitors, cause most of them
can only make it after work.
He feels very unpleasant smells and sees very sick
patients. He’s afraid of that and of the possibility of getting
something himself. After passing several oors and corridors,
he reaches the ward where his mother is. There are other
people in the ward, so they can’t have a normal chat. They
can go to the yard and talk more privately and have a walk.
“ As a patient, I want a private and comfortable room which has supportive
environment but exible and have lots of function such as sit, stand, low-down and
look outside. Outdoor environment must be quite good, the I can have a good view.
A exible space that could change quite easily and I can get all the things quite easy
and cured. A private room should be good but sometimes I want to communicate
with other patient, doctor or nurse. So it may be just half-open. The room should
be a good place to release my stress and pressure, as comfortable as my home.
Also it should be a quiet place, cause I don’t want to hear other patients moan in
my room. Some connection with nature is needed, I know that I can’t be outside,
but I want to see nature.”
HEALING ENVIRONMENT:What to take into account.
HEALTHY
SPACE
STAFF
PATIENT
VISITOR
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though with time this has been also questioned.
After building data and analysis of results, by publica-
tion on different matters, Evidence based Design (EBD) could
be implemented in new projects and renovations through out
the globe. This as a tool was perfect for architects to convince
their clients, Institutional managers to guide their boards and
medical staff to demand changes. The body of research and in-
formation is building day by day and not only that, it is getting
updated, which present a new challenge: what was efcient or
preferable yesterday, might not be today.
As every architectural approach EBD has to respond to
a multi-sensorial demand, in its core regards the health impact
of a particular environment on patients, staff and visitors as aguiding principle of design. So from Ulrich’s connection between
view and pain, many studies and researches were made for dif-
ferent factors as light, colour, sound, control and distance. After
many actions were implemented in different settings the main
factors for comparing results and weight its validity are: patient
clinical outcome, staff recruitment and retention and facility op-
erational efciency.
Though many factors are in play at the time of recovery
one that showed to be one of the most inuential in all three
NATURE
The view or perception ofnature brings the patienta sense of calm, reducingstress levels.
POSITIVE D I S -
TRACTIONElements like art and activi-ties help to scape from thehospital environment, creat-ing a break in the routine.
LIGHTThe view or perception ofnature brings the patienta sense of calm, reducingstress levels.
SAFETYSecure environment reduc-es stress, but in a higherdegree avoids unnecessaryinjuries and complications.
SOCIAL SUPPORTIs an important factor forpatients to feel at ease in anew environment.
CONTROLIs an important factor forpatients to feel at ease in anew environment.
NOISEIts reduction affects notonly in the patient but alsothe staff, translating in lessstress and medical errors.
AIR Air transmitted infection is aserious issue, since is a highfactor for extending staysdue to new complications.
factors is stress reduction. It was discovered that over the exist-
ing stress experimented by medical procedures, many features
of the same hospital actually help increase the environmental
level of stress for the patient.
The reduction of stress is not important just for reducing
stress itself, but for the side effects that come with it, not only
for the patient but also for the staff and physicians .Shorter
outcomes, less medical errors and fewer prescribed medication
are some of the benets that addressing stress can mean for a
health care facility, so it’s not only a better service but a more
economic one also.
Research has proven that the actual design can inuencemedical outcomes by mitigating stress or increasing safety,
that is why the focus today for most facilities are : reduction
of stress, patient and staff safety, and energy and resource ef-
cient building.
So what does a healing environment consist of? The
main considerations that are mostly agreed in the overall com-
munity are:
_Connection to nature, Option and Choices, Positive Dis-
tractions, Access to social support, Environmental stresses
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NoiseFrequent overhead announcements, pagers, alarms, and noisy
equipment in or near patient rooms are stressful for patients
and interfere with their rest and recovery.1 Single-bed rooms
with high performance, sound-absorbing ceilings and limited
overhead announcements can substantially improve the heal-
ing environment for patients.2
1 Nelson C, West T, Goodman C. The Hospital Built Environment: What Role
Might Funders of Health Services Research Play? Rockville, MD: Agency for Health-
care Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
2 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital
of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for
Health Design; 2004 Sept.
StressThough is a very normal condition, today’s levels of stress are
not only higher but also present in a larger group. The known
risks, that everyone has experienced at least once, are only the
supercial signs of more relevant effects in the body. On top of
everyday stress, patients accumulate a higher level provoked
by anxiety, confusion, fear and worries provoked by the medical
procedure and clinical environment. One of the characteristics
less know about stress is probably its duration that can last for
hours after an stressful event. Independen t from the procedure
stress produces a hormone that also lowers the threshold of
pain, giving the patient a higher pain sensation.
But this condition actually not only affects the patient but in
great measure affects the medical staff. By overloads of re-
sponsibility, lack on material and staff, and inadequate facilities
for the required tasks, health workers become a highly stress
group, which is directly transferred to the patient, creating a
vicious circle.
BRAIN AND NERVES
Headaches, feeling of despair, lack of energy,
sadness, nervousness, anger, irritability,
increased or decreased eating, troubleconcentrating, memory problems, trouble
sleeping, mental health conditions, such as :
panic attacks, anxiety disorders and depres-sion.
SKIN
Acne , irritation other skin problems.
MUSCLES AND JOINTS
Muscle aches and tesion, especially in the
neck, shoulders and back. Increased risk of
reduced bone density.
HEART
Faster heartbeat, rise in blood preassure,
increased risk of high cholesterol and heart
attack.
STOMACH
Nausea, stomach pain, heartburn, weight gain.
PANCREAS
Increased risk of diabetes
INTESTINES
Diarrhea, contipation and other digestive
problems.
REPRODUCTIVE SYSTEM
For women: irregular or more painful periods,
reduced sexual desire. For men: impotence,
lower sperm production, reduced sexualdesire.
INMUNE SYSTEM
Lowered ability to fight or recover from illness.
HEALING ENVIRONMENT:Factors and Effects.
Errors & Safety
Medical Errors: Poor lighting, frequent interruptions
and distractions, and inadequate private space can complicate
lling prescriptions. Well-illuminated, quiet, private spaces al-
low pharmacists to ll prescriptions without the distractions that
may lead to medication errors.
Patient rooms that can be adapted for the acuity of a
patient can also reduce errors. Acuity-adaptable rooms reduce
the need to transfer patients around the hospital and lessen the
burden on the staff to communicate information to caregivers in
the patient’s new location.3
Patient falls: Patient falls, which are common in hospi-
tals, can result in serious injuries, extend a patient’s stay, and
drive up the cost of care signicantly. By 2020 the estimated
annual cost of fall injuries for older people will exceed $30 bil-
lion.7,8 Now that the Centers for Medicare and Medicaid Ser-
vices no longer reimburse hospitals for the cost of patient falls
that occur in their facilities, and insurers are likely to follow its
lead, hospitals will bear a greater portion of this cost.
Poor placement of handrails and small door openings are
3 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital
of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for
Health Design; 2004 Sept.
28%of health care workers report
a higher than average degree of
stress compared to 18% of the
general population.
bmj.com
two primary causes of patient falls. Many falls can be reduced
through providing well-designed patient rooms and bathrooms
and creating decentralized nurses’ stations that allow nurses
easier access to at-risk patients.4
4 Transforming Hospitals:Designing for safety and Quality. Agency for
Healthcare and Quality, US. 2007
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INFECTIONSingle-bed rooms and improved air ltration systems
can reduce the transmission of hospital-acquired infections.
Infections can also be reduced by providing multiple locations
for staff members to wash their hands so they spend less time
walking to sinks and have more opportunities to sanitize their
hands before providing care.5 One of the most effectives meas-
sure in to have a sink in every room entrance, in plain sight and
in the nurses working path for accesibilyty and also the patient
can supervise the medical staff’s cleaning habits.
5 Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital
of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for
Health Design; 2004 Sept.
NATUREOn a rst aproach we can all agree the looking at nature
has a traquilising effect and that it provokes a positive outcome
in our current condition, for patient it has been proven that this
is more than just a personal impresion but a fact:
“a view nature on a screen or view can reduce stress
and pain”
“Indoor Plants lift people’s mood and reduces self-re-
ported symptoms of physical discomfort”
Healing By Architecture,
Agnes Van den Berg and Cor Wagenaar.
Several theories have evolved to address the question ofNature having a “healing” or restorative condition. In learning
theories, the subscribers suggest that man has learned to pre-
fer nature. For example, people may have learned to associate
restorative experience with nature because of vacations spent
in beautiful settings or long childhood summers spent on the
beach, or near a lake or stream.
Urban settings, on the other hand, bring back images
of trafc, congestion, work pressure, lth, or crime. Cultural
theories propose that we are taught by society to have positive
feelings towards certain types of environments. For example,
Native American and Asian cultures have taught their peoples
to respect nature.
Environmental preference studies have shown that a
natural setting is the view of choice. Charles A. Lewis refers
to it as “green nature”(Spriggs et al., 1998). Gordon Orians
and Judith Heerwagen, in their studies on landscape aesthetics,
have shown that people prefer open, distant views with scat-
tered trees, water, and refuges and paths that suggest ease of
movement. In studies of users of some urban parks, properties
such as vegetation, water, and savanna- like qualities, such as
scattered trees, grass, and spatial openness, seemed to cor-
relate with ratings of restoration (Ulrich and Addoms, 1981). In
his article, Healing Words, J. William Thompson quotes experts
in the eld of healing garden design:
“Anything green makes patients feel better, any plant,
any tree,” and “…if they wish to create truly healing spaces,
landscape architects would do well to discover – or rediscov-
er—the wonder of the plant kingdom”
Landscape Architecture,
Jan. 2000:54-75
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LIGHTProbably one of the most abundant resources and with
high impact in patient recovery is daylight. Though daylight is
recommended, sunshine must be controlled, avoiding glare and
too much reection on the patients bed. There are many factors
that will determine the light situation in a project and is needed
to take them into account:
(northern hemisphere guides)
GUIDELINE 1
Orientation and Location
The direction of the building will determine solar gains in ra-
diation, though this must be determined also by the particular
climate zone, the specic site, an external factors present in
the place. Is not possible to dene a universal orientation for
healthcare buildings because of functional and individual char-
acteristics, but is possible to dene advantages and disadvan -
tages of different orientations:NORTH-SOUTH: The negative is that minimizes the souther, and
most preferred facade. But it avoids th e northern faced rooms,
giving all some light during the day.
EAST-WEST: Maximizes desired southern facades with simple
and easy sun control strategies. Creates a clear distinction with
norther facades, that will not get any direct sunlight.
GUIDELINE 2
Sun Control
As paradoxical as it sound, the worst enemy of daylight is the
sun itself, that is why efcient and thought strategies for shad-
ing must be implemented, to avoid heat gain and glare. Thisstrategies will take effect mainly in the southern (all day) and
western (afternoon) facade. The role of the system i s to control
thermal and visual comfort of its occupants and to support the
heating and cooling system loads. Since the sun is an always
moving source, not only throughout the day but during seasons,
is necessary not only to shade but to control and redirect the
given light in an efcient manner to the interior of the building.
DAYLIGHT SOCIAL/ECONOMIC BENEFITS
Though buildinga highly perforatedbuilding may be more costly,this investmentwill translate in severallong term benefits and
savings for the institution such as energy savings. But on anotherlevelthere is a greatpotentialto reduce the costrelatedto staffmembers by increased satisfaction, reduce stress levels andincrease productivity andconcentration, which results in lower
medicalerrors rates.
DAYLIGHTCANBE USED TO IMPROVEILLUMINATION LEVELS. HIGHILLUMINATIONLEVELS MAY RESULTIN
FEWERERRORS.
Daylightin a workplaceis the mostpreferred
source of lighting.(Mrochzek etal.,2005)
Nurses being exposed to daylight for more than 3hours during their work showed l ess perceivedstress, higher job satisfaction and lower intention
to quit in comparison to nurses with a daylightexposure less that 3 hours per day.(Alimoglu,M.K.,& Donmez, I.,2005)
Environmentalsatisfaction is high if ismore likely thatoverall
satisfaction in hospitalswillbe also high.(Harris etal., 2002)
DAYLIGHT AND ECO-EFFICIENT
GREENHOUSEGAS EMISSIONS.Comparison between hospitals inU.S., Germany andNorway.
THENEED OF REDUCINGENERGYCONSUMPTION:HEALTHCAREARCHITECTUREAND GLOBAL HEALTH
With appropriate controlfor HEATGAINand GLARE, daylightinghas the potentialto reduce energy consumption neededfor lighting
ENERGYUSEINHEALTHCAREFACILITIES
ELECTRICITYCONSUMPTION
_Data from U.S. NationalDatabase:The CommercialBuildings EnergyConsumption Survey (CEBECS)
_Arqum Gesellschaftfür Arbeitssicher-heits/Qualitäts-und Umweltmanage-mentmbH (2008).Abschulssberichtzum durchgeführten Projekt
"Energieeffizienztisch" für Kranken-häuser in Rheinland-Pfalz
_Burpee, H., etal., 2009. High
Performance HospitalPartnerships:Reachingthe 2030 Challenge and
Improvingthe Health andHealingEnvironment
_Burpee, H., etal., 2009. High
Performance HospitalPartnerships:Reachingthe 2030 Challenge and
Improvingthe Health andHealingEnvironment
280 KBtu/SF/year=
116 lbCO2/SF/year
Average carbon dioxidemission of U.S. Hospitals.
104 KBtu/SF/year=
43 lbCO2/SF/year
Average carbon dioxidemission of German Hospitals.
127 KBtu/SF/year=
52 lbCO2/SF/year
Average carbon dioxidemission of Norwegian Hospitals. (Rikshospitaland St.
Olavs)
60 %Fuel
40 %Electricity
13%of electricity
consumption is usedfor lighting.
_Energy type usedin Health
care buildings in the U.S.USDepartmentof Energy.
_Electricity Consumption(TotalBTU)by EndUse forHealthcare Buildings in theU.S. in 2003. Released2008
(US Departmentof Energyinformation Administration)
0 4 0 6 0 8 0 1 0 0
1 2 0 BTU
Space Heating
Cooling
Ventilation
Water Heating
Lighting
Cooking
Refrigeration
Office Equipment
Computers
OtherOther
SAFETY
DAYLIGHTCANBE USEDTO IMPROVEILLUMINATIONLEVELS. HIGHILLUMINATIONLEVELS MAYRESULTINFEWER ERRORS .
_Buchanan, T.L., Barker, K. N., Gibson, J.T., Jiang, B.V., & Pearson, R.E. (1991). Illumination anderrors in dispensing.American Journalof HospitalPharmacy, 48(10),2137-2145.
! !
! !
! !
!
3.8%error rate
2.6%error rate
DAYLIGHT AND HEALTH
REDUCE LENGTH OF STAY MORTALITY RATE
Room withoutdirectsunlight
16.9% 16.9%
Room withdirectsunlight
North facingroom
South facingroom
19.5% 16.9%
_Beauchemin, K.M. & Hays, P. (1996). Sunny hospitalroom expediterecovery from severe andrefractory depressions. JournalofAffectiveDisorders, 40 (1-2), 49-51.
_Beauchemin, K.M. &Hays, P. (1996). Dyingin the dark, Sunshine,gender andotcomes in myocardialinfarction. Journalof the RoyalSociety of Medicine, 91(7), 352-354.
MEDICATIONCOST
Less painMore pain
_Walch, J.M., Rabin, B.S., Day, R., Williams, J.N., Chai, K.,&Kang,J.D. (2005). The effectof sunlighton postoperative analgesicmedication usage:A prospective study of spinalsurgery patients.
Psychosomatic Medicine, 67 (1), 156-163.
22%LESS
A C C E S S T O D A Y L I G H T A N D V I E W T O
N A T U R E I MP R O V E S R E C O V E R Y P R O C E S
D A Y L I G H T R E D U C E S
E N E R G Y C O N S U MP T I O N
B R I G H T L I G H T MA Y R E S U L T
I N F E WE R E R R O R S
MI G H T I N C R E A S E P R O D U C T I V I T Y , S T A F F
S A T I S F A C T I O N A N D R E D U C E T U R N O V E R
Patients to an increased intensity of sun-
light experienced less, perceived stress, less
pain, took 22% less analgesic medication per
hour and had 20% less pain medication costs.
Ulrich, 2004.
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CONTROLTo reduce anxiety on the patient is necessary to reduce its sense
of lack of control, by giving them the needed information an
tools to make decisions and prepare themselves for following
tasks or procedures. Most of the times patients are carried
through the building with no clear explanation of where they
are or where they are going, creating an unclear an frightening
scenario. Intuitive waynding, ceilings is what patients sees, so
there must be effort in strengthening these aid and also creat-
ing a readable space, so is not necessary to explain everything
but the building becomes self explained.
Helping patients effortlessly nd their way through hospitals can
improve patients’ overall care experience and increase satisfac-
tion by reducing feelings of stress, anxiety, and helplessness
for them and their families. Better navigation can be addressed
architecturally through useful signs and easily navigable cor-
ridors.6
6 Nelson C, West T, Goodman C. The Hospital Built Environment: What Role
Might Funders of Health Services Research Play? Rockville, MD: Agency for Health-
care Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
COLOURColour is a non built element that really impacts the space,
most of the time is disregarded as a secondary and decora-
tive role, without weigh-in its possible effects. Is also one of
the elements that is characteristic for a hospital, where people
realtes to certain shades, evoking medical treatment. Nowa-
days after many polls and interviews with user is known that
though white is prefered through out the different spaces, the
use of colour is now recomended, avoiding huge planes of a
plane washed out colour for more intense but conned ones.
The colour is also a powerfull tool for orientation, information
and spatial clearnes.
2 , 7 2 %
39,95%
12,05%
24,23%
14,78%
6,27%
1 , 3
%
32,2%
7,4%
19,9%
36,0%
3 , 0
%
Patient Room
3 , 8
%
39,6%12,4%
15,2%
23,1%
6,0%
Work Places
53,7%
2 , 8 %
19,6%
9,0%
7,9%
7,09%
Sanitary Facilities
3 , 0
%
34,3%8,8%
17,0%
28,8%
8,2%
Corridors
Graphics of the ideal colours to use inside the Ward ac-cording to the personnel.
(Source: Research Project Working-Place Hospital)
PATIENT ROOMThe room must be one of the most important places in
a hospital, is where the actual healing takes place. Small space
full of small decisions, like having a broader free space on the
entrance side of the bed for easier medical access. The role of
distances play a huge role, specially the one toward the bath-
room, not only should be short but also continuos surface from
the bed, to avoid falls.
Single room are in demand, because of infection but also
practical issues: reduce risk of infection, stress from noise and
transfer rates which is a high cause of medical errors. Also is
more comfortable to welcome the family.
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42 43
Healing Environment: Is the result on a EBD that has
demonstrated measurable improvements in the physical and/
or psychological state of patient and/or staff, physicians, and
visitors.
Should make a therapeutic contribution to the process
of restoring someone’s health. For what it should be more than
just intuition (most practices) it has to be proven with on site
eld research and answer: Who was healed? How do we know?
EBPractice: designers make critical decisions together
with an informed client, on the basis of the best available infor-
mation from credible research and the evaluation of completed
projects.
Performance Based Building Design (PBBD): attemptsto create clear and statistical relationships between design de-
cisions and requirements satisfaction levels evidenced by the
building systems.PBBD uses research evidence to predict per-
formance related to design decisions. however, the decision
making process is not a linear one: for the build environment is
a complex system. Choices cannot be based on simple cause-
and-effect predictions; instead they depend on many variable
components and on the mutual relations established one each
other.
Four Levels of Evidence-Based Practice
Level 1:analysing the literature in the eld in order to fol-
low the related environmental researches reading the meaning
of the evidence in the relationships to the project
Level 2: foreshadowing the expected outcomes of de-sign decisions upon the general readings measuring the results
through the analysis of the implications, the construction of a
chain of logic connection from decision and future outcome, in
order to reduce arbitrary decisions
Level 3: reporting the results publicly, writing or speak-
ing about results, and moving in this way information beyond
design team subjecting methods and results to others who may
or may not agree with the ndings
Level 4:publishing the ndings in reviewed journals col-
laborating with academic or social scientists
PHYSIOLOGICAL
IMPACTS
Healing
Pain
Infection
Cardiac Rhythm
Exercise
Admition time
Medical Errors
Accidents
PHYCHOLOGICALIMPACTS
Comfort
Orientation
Economical
Control
Satisfied Staff
ELEMENTS FOR
DESIGN
Site
Orientation
Layout
Functionality
Interiorism
Materials
Equipment
Envelope
Flows
Connections
PARAMETERS
View
Light
Art
Colour
Sound
Airflow
Privacy
Social Rooms
Acces to nature
Safety
Wayfinding
Hygiene
Current Hospital design is
focused on analysing the dif-
ferent impacts that their ac-
tions can improve or create.
EBD bases all its knowledge
in the analyse and research
of this mostly quantitative ef-
fects, because of its scientic
approach, for the rest environ-
mental psychology plays an
important role, backing up the
knowledge.
Though the architectural el-
ements don’t change much
from a traditional project, the
relations change. Is important
to bring to surface the hidden
links and be aware of the end
results that a single decision
can achieve. Many practical is-
sues are mostly regarded, but
the relation to more soft val-
ues show an important role on
their impact.
These parameter summa-
rise the quest for a better and
healthier environment. Creat-
ing a strong set of guide lines
for the design process, that
comes as a result of system-
atic research, revealing hard
data and trustworthy param-
eters meant to be addressed
at the project.
EVIDENCE BASED DESIGNGuidekines and Method by Research
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H
“... built catastrophes, anonymous institutional complex-es run by vast bureaucracies, and totally unt for the purposethey have been designed for ... They are hardly ever function-al, and instead of making patients feel at home, they producestress and anxiety.” 1
1 a b Healing by design – Ode Magazine, July/August 2006 issue. Accessed2008-02-10.
M A L M Ö H O S P I T A LMaximize the OPPORTUNITIES within
an EXISTING building
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46 47
1812
1912
1939
2010
The Hospital was founded in the outskirts of the city, as
a green complex almost as a continuation of Pildmmsparken.
The Pavillion arrangement followed that premise, as an open
arrangement standing in a park like site.
Nowadays the hospital stands where the city has been
growing and expanding.
It is split by a former urban limit , as is the road that
conects the airport and the city. As a response, the complex
was densied in the same “free standing building” scheme, but
without following any urban logic.
MALMÖ UNIVERSITY HOSPITALHistory and Context Rigshospitalet
Copenhagen University Hospital
46,5 km 43 minutes
Lund Hospital
Lund University Hospital
20,5 km 18 minutes
i i i ,
Temperature,(Celcius)
January
February
March
April
May
June
July
August
September
October
November
December
m r tur( l si u s, )
20
15
10
5
-5
-10
-15
Rh,Precipitation,(percentage/cm)
January
February
March
April
May
June
July
August
September
October
November
December
, r i i t t i n( r n t , m )
80
70
60
50
40
30
2
0
5
9
Averagewind direction,(km/h)
N
NNE
NE
ENE
ESE
SE
SSESSW
SW
WSW
WNW
NW
NNW
W E
S
201510
J nu r
F r u r
m r
m r
m r tur( l si u s, )
2
1
1
J nu r
F r u r
m r
m r
, r i i t t i n( r n t , m )
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48 49
MALMÖ UNIVERSITY HOSPITAL Vision
The mission is to develop a sustainable plan for the hospital inMalmö. The hospital’s physical environment and structural en-gineering status have been investigated. Existing buildings cannot meet future requirements for high-tech care, such as surgi-cal and intensive care. Current health care buildings have littleopportunity be converted into units of one-patient rooms, butshould be in less term to serve as day care and reception. Ma-ture where buildings need to be supplemented in order to serveas administrative premises. Some Hospital Activities today arerented premises on the South area and Sege park will eventu-ally move in and be assured a place in the area.
Hospital district of Malmö, the region’s largest employer, cen-trally located in Malmö and with close links to the City Tunnel.A well-developed City of integration synergies and developmentopportunities for both Region Skåne and Malmö City. Ongoingplanning work with this starting point and a common missionstatement has been established in cooperation between the City
and Region Skåne. Region Skåne Ongoing planning activitiesare primarily designed to establish a robust development struc-ture for the hospital area and to study a number of areas ordevelopment scenarios, which can form the basis for detailedplanning of future expansion phases. Proposal for overall plan-ning and design details of this Property Development Plan havebeen addressed in a number of working meetings between theproject team and City Planning
To develop a modern hospital with high demands on functionalrelationships at all levels in the surrounding urban environmentis a major task. The buildings must be integrated into the sur-rounding neighborhood structure, creating attractive humanenvironments and enhance the architectural values. City Tunnelup from Triangeln way is on blocks just north the hospital and
others fate of this hub for public transport ken and the hospitalshould have an obvious and clear design.
A new service terminal proposed in th e southeast corner of thehospital campus with entrance from John Ericsson pa th. Wheref NNS also able to place certain technical services and otheroperational functions. The block is strategically in relation totransportation and an extensive culvert system.
The proposed coherent block structure of the hospital campusoccur as a result of the concentration of the medical care activi-ties, more perical area that can be utilized by other functions.The extent of these surfaces is dependent on strategic