Hospital Design Guidelines

THE GENERAL HOSPITAL

BUILDING GUIDELINES FOR NEW BUILDINGS

(reportnumber 0.107)

Adopted by the Netherlands Board for Hospital Facilities on 7 October 2002

Approved by the Minister for Health, Welfare and Sports on 19 November 2002

General hospital building guidelines

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CONTENTS

1. INTRODUCTION 1

2. GENERAL PRINCIPLES AND PRECONDITIONS 22.1 Principles 22.2 Preconditions 22.3 Supplementary areas 2

3. BASIC PRINCIPLES IN RELATION TO CARE 43.1 Upscaling 43.2 Specialist medical care 43.3 Organisation of care 43.4 Differentiated care 83.5 Design of the general hospital building guidelines 9

4. BASIC QUALITY REQUIREMENTS 114.1 Introduction 114.2 Reachability 114.3 Access 114.4 Flexibility 12 4.5 Spatial relationships 134.6 Quality of the environment 14

5. ARCHITECTURAL CONCEPTS 155.1 Introduction 155.2 Breitfuss model 165.3 Double comb structure 175.4 Arcade structure 195.5 Cross structure 205.6 Branched structure 225.7 Linear structure 245.8 Pavilion structure 26

6. FINANCIAL ASPECTS 296.1 Building development investment costs framework 296.2 Practical application 30


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1. INTRODUCTION

These building guidelines concern the spatial facilities for a general hospital with basic qualityrequirements at the level of the hospital as a whole. Together with the basic quality requirementsincorporated in the specific guidelines for specific functions of a hospital, they form the complete set ofbasic quality requirements with which building plans for new hospitals have to comply.

The building guidelines were adopted by the Netherlands Board for Hospital Facilities (Bouwcollege) in aresolution passed on 7 October 2002, taking into account article 15a of the Hospital Provision Act(WZV), and approved by the Minister for Health, Welfare and Sports on 19 November 2002.As appendix 1.01, the guidelines form part of the Hospital Provision Act Building Standards Regulations.Please refer to the general section of the explanatory notes to the Netherlands Board for HospitalFacilities Regulations ‘General Hospital Building Standards’.In the Building guidelines Care Sector brochure, there is a description of the use of the guidelines andhow they were developed. This brochure can be ordered from the Netherlands Board for HospitalFacilities. It can also be downloaded via the Board’s website: http//:www.bouwcollege.nl, where you willnot only find these guidelines but also the specific guidelines for specific functions of a hospital, as wellas other relevant publications.

Chapter 2 deals with the general principles and preconditions when compiling and applying the buildingguidelines.Chapter 3 gives the basic principles related to care that form the foundation of the guidelines, based onevaluation and experience.Chapter 4 describes the basic quality requirements at the level of the hospital as a whole.Chapter 5 includes various architectural concepts with an explanation of how the basic qualityrequirements described in chapter 4 have been or will be incorporated in the building structure of ahospital.Chapter 6 deals with the spatial and financial conditions related to building a new hospital.


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2 GENERAL PRINCIPLES AND PRECONDITIONS

2.1 Principles

Building guidelinesBuilding guidelines are a tool to help prepare building initiatives in the healthcare sector. They also forman evaluation framework for the architectural and functional assessment of building applicationssubmitted by institutions.Building guidelines not only provide a description of the minimum space needs and functionalrequirements with which new care facilities have to comply. They also represent a reaction todevelopments in the healthcare sector in recent years and, where possible, provide a picture ofdevelopments in the immediate future (chapter 3).Building guidelines comprise two parts: basic quality requirements and cost norms.

Basic quality requirementsThe Basic Quality Requirements describe the minimum requisite level of quality with which certainfacilities or accommodation must comply in terms of functionality, safety and hygiene, whereby adistinction can be made between “closed” and “open standards”.The term “closed standards” refers to standards that are clearly quantifiable. In the case of hospitals,this may refer for example to minimum dimensions of patient rooms or spatial and technicalrequirements for operating theatres and laboratories.“Open standards” mainly consist of generally endorsed guideline criteria that are difficult to quantify. Asa rule, these “open standards” refer to aspects that particularly play a role at a level of the hospital as awhole, such as the flexibility of the building structure or the quality of the built environment.Chapter 4 goes deeper into the above-mentioned basic quality requirements.

Cost normsThe guidelines have been flexibly designed so that, given the basic quality requirements, varioussolutions are possible within specific frameworks. With respect to the building of WZV Hospital ProvisionAct facilities, these frameworks are principally determined by maximum permissible investment costs.Chapter 6 describes how this investment cost framework is determined and how it is applied in practice.

ScopeAppendix 1 states for which hospital functions the basic quality requirements (will) apply. The basicprinciple in this respect is that only the patient-related functions of a hospital will be applicable for this,such as nursing, diagnostics and treatment and medical supporting facilities (laboratories, pharmacy,central sterile supply department). With regard to the other, usually general and technical supplyfacilities, no basic quality requirements will be imposed with the exception of the kitchen facilities. It isthis aspect that gives the standards their flexibility.

2.2 Preconditions

When drawing up the guidelines, account was taken of regulations relating to environment legislationand regulations applicable to building in general. Examples include the Buildings Decree (relating tostorey height, daylighting and ventilation regulations etc.), the Building Access Handbook (wheelchairaccess), the Working Conditions Act (relating to the use of sling hoists etc.) and the Tobacco Act (thatstates that patients and staff must be able to function without hindrance caused by the use of tobaccoproducts).

2.3 Supplementary areas

The above-mentioned guidelines are limited to facilities for functions that a care provider must or canprovide. During realization of these facilities, it may be necessary to pay attention to other aspects that


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are either related to or a consequence of the building activities. Examples of this include acquisition ofland, site size, parking facilities, interim facilities or technical installations.Attention is paid to these aspects in other publications of the Netherlands Board for Hospital Facilities(http://www.bouwcollege.nl). In instances where these publications may be of relevance, reference ismade to them in this text.


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3. BASIC PRINCIPLES IN RELATION TO CARE

3.1 Upscaling

Since the nineteen seventies, there has been a trend towards upscaling. This is due to a number ofcauses. On the one hand, developments in the field of the medical profession as such, for exampleincreasing specialisation, quality requirements laid down by the professional associations and theintroduction of expensive medical technology, lead to upscaling. On the other hand, government policyhas encouraged concentration. From the mid-seventies, policy aimed at reducing the number of bedshas led to amalgamation with new buildings as a survival strategy for the smaller hospitals. From themid-eighties, mergers took place on the basis of strategic considerations, in anticipation of theannounced introduction of market efficiency in the healthcare sector. Furthermore, the hospital budgetincluded a ‘merger premium’. This referred to the premium related to the scale based on the assumptionthat large hospital in principle treats more complex patients, due to having a more extensive range offunctions.

This upscaling led to a decline in the number of hospital organisations, but not to an equivalent reductionin the number of hospital locations 1. In order to maintain access to hospital care for the general publicas far as possible and also for strategic marketing reasons (retention of market share), amalgamatedhospital organisations often opt to keep locations open and divide functions differently over thelocations. Complex care and relatively expensive facilities such as general intensive care and cardiaccare consequently tend to be concentrated.

3.2 Specialist medical care

Developments in medical knowledge and science (applicable to healthcare) have led to extensive super-specialisation and sub-specialisation of physicians, as a result of which the need for intra-disciplinarycooperation has radically increased.Developments in concepts about hospital care and care organisation, in which the wishes of patients arenow playing an important role, have created a need for interdisciplinary cooperation to grow. Sub-specialisation, part-time work and the quality requirements of professional associations (that are oftenalso applied by the Inspectorate) have led to larger partnerships. The increasing juridification of theprimary process also has an impact on the development of the quality requirements of the professionalassociations: patients have an increasing tendency to go to court. In addition, the scarcity of medicalstaff can also result in concentration.Nor has medical technology stood still. This has led on the one hand to the necessary concentration ofhospital care because it is only at a certain scale and production level that very expensive equipmentcan be efficiently used, while on the other hand medical technology has also enabled medical specialiststo function on a small-scale. ICT has naturally made an important contribution to all of this, at bothdiagnostic and therapeutic levels and at a communication level.

3.3 Organisation of healthcare

Until a few years ago, organisation of healthcare was largely based on the perspective of the medicalspecialisations available in a hospital and the availability of diagnostic and treatment facilities.Furthermore, due to the largely monodisciplinary approach to the patient’s care requirements, virtuallyevery specialisation had its own beds in the ward unit and diagnostic and treatment facilities in theoutpatient unit.As a result of the developments in specialist medical care described in § 3.2 together with the fact that,due to an increasing shift from inpatient to outpatient care and day treatment, inpatient care is being

1 Netherlands Board for Hospital Facilities: Feasibility study on desired distribution of hospitals 7 November 2000


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increasingly reserved for complex and difficult medical cases, attention has been paid in recent years toa more integrated organisation of healthcare, based on the patient’s perspective.This trend has led to a reorientation regarding the way in which the demand for hospital care is offered.This reorientation process concerns the logistic process in both the hospital organisations and the entirecare chain. In broad terms the following categories may be distinguished. Although these displaysimilarities, a different emphasis may be placed on a number of aspects with regard to the organisationof the care.It is consequently also possible to combine the different planning models. The choice and detailing ofthe organisation of the care is dependent on the situation and is largely determined by weighing up theinterests of the patient and the care provider in relation to management (scale size).

Planning on the basis of target-groups/clinical entities

The basis of this model is clustering activities as far as possible around the treatment of the patient,whereby a distinction is generally made according to care units and supporting units.The care units concern the primary process, patient care. This is based on grouping the differentspecialisations present in the hospital, aimed at achieving a more or less comprehensive range of carefor patients with similar clinical entities.Classification into care units/themes depends on the care profile of a hospital, whether or not certainspecialisations are present, the scope of the existing specialisations and the hospital’s policy andprofiling. Examples of care units/themes include ‘mother & child’, ‘oncology’, ‘brain & sense organs’ and‘heart & vascular’.

The supporting units are focused on medical and general & technical support for the primary process.Medical support includes imaging diagnostics, general organ function investigation, the pharmacy andthe laboratories. General & technical support mainly comprises facilities for management, such asadministration and provision of information, central kitchen, technical service and personnel facilities.

In practice, it is shown that the functional and spatial planning of the above-mentioned units can betackled in different ways.Some projects have opted to combine inpatient and outpatient activities within one care unit, with theincorporation of medical supporting functions. Other projects on the other hand have chosen a moretraditional form of planning in which a greater distinction is advocated between inpatient and outpatientcare and diagnostics. In this situation, the care process around the patient is generally based on theprinciple of virtual multidisciplinary cooperation. These are forms of cooperation that are notrecognisable in a physical sense. The medical specialists work together around one patient group but donot have office visits at the same time at one location. It is determined by means of protocols in whatmanner the different specialisations and medical supporting facilities are used in the treatment of thepatient group.

Theme 1: Brain & sensory organsTheme 2: OncologyTheme 3: Immune system, metabolism & agingTheme 4: Acute care & musculoskeletal systemTheme 5: Heart & vascularTheme 6: Growth, development and reproduction


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Source: Erasmus MC Rotterdam

Planning on the basis of patient flows

In this model a distinction is made between four patient flows: acute care, urgent care, elective care andchronic care. The underlying principle of this subdivision is the assumption that each patient flowbasically differs from the other in terms of atmosphere, organisation, planability, position ofprofessionals, relationship with referrers and follow-up care and the building aspect.

The acute care unit only deals with patients who are in a truly life-threatening situation. This is in fact awell-equipped emergency department where mainly patients with severe trauma and injury are treated.

The urgent care unit deals with patients in cases where a few hours between registration at receptionand treatment will not lead to problems. With urgent care there is time between registration and carryingout diagnostic procedures and treatment. This time is used to gather information about the patient, toprepare the treatment plan within the hospital or arrange any follow-up care. A large proportion of thepatients who are currently (wrongly) admitted to the emergency care unit will be treated in the urgentcare unit. An observation unit forms part of the urgent care unit. The purpose of the urgent care unit is torelieve pressure on the adjacent acute care unit (emergency department) as far as possible.

Elective care concerns care when there is a period of time (days, weeks) between registration and anappointment. Elective care can usually be well planned. In order to safeguard this planability, it isnecessary to determine what has to be achieved with each patient target-group (the objectives).Agreements are made between general practitioners, medical specialists, patient associations and otherparties involved about admission waiting-time, total treatment time, allocation of tasks and responsibility.

Chronic care concerns care where a long-term relationship with the patient is required. This type of caredemands a strong personal contact in a relaxed, non-hospital-like atmosphere. A great deal of attentionis paid to providing information and counselling to the patient, relatives, other parties concerned and thereferrer. Examples of chronic care are patients with heart failure, back problems, lung/asthmaticconditions and diabetics.


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Source: Deventer Hospitals

Planning on the basis of the care process

This model is largely based on the stages through which a patient passes from the moment the patientarrives in the hospital until the moment he/she leaves it. Six main processes may be distinguished here,as follows:• treatment from the general practitioner, resulting in referral;• screening and diagnostic procedures;• appointment with the specialist(s) to discuss the diagnostic results, advice, treatment possibilities

and treatment planning;• treatment in different forms;• care in different forms;• aftercare in different forms.

Grouped around these main processes are ICT, the organisation and the facilities, resulting in sixdifferent centres:1. the centre for screening and diagnostics where investigations can be carried out;2. appointment centre where consultations take place;3. the treatment centre where treatment is carried out;4. the nursing centre where nursing takes place;5. the logistics centre from which support is given to the above-mentioned centres;6. the knowledge/expertise centre where the professionals (in the broadest sense of the word) have a

place to work and meet each other.

This model is based on the assumption that modern ICT techniques are applied, aimed at integratedplanning of the care process – not only in the hospital but also outside.The basic principle is that professionals in the care chain must be able to consult all informationindependent of time and place. This means that all information must be digitally available.


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Source: Orbis Sittard

3.4 Differentiated care

The developments described above have led to a wide variety of forms of hospital care2, such as:• general practitioner centres in hospitals;• the external outpatient unit that provides outpatient care during office hours (an independent

treatment centre can fulfil this description);• the day hospital that provides general, specialist medical care that is not too complex, but where no

24-hour care is provided (an independent treatment centre can fulfil this description);• the specialised hospital that concentrates on certain sections of hospital care or certain target-

groups and where 24-hour care and/or day nursing is provided;• the general hospital where a distinction can be made between a basic hospital and a top clinical

hospital/intervention centre;• the university teaching hospital.

The above-mentioned forms of hospital care occur in different organisation forms, varying fromindependently operating entities to a combination of facilities under one hospital organisation or in acooperative organisational form.Appendix 2 gives a number of examples regarding a possible constellation of hospital care spread overseveral different hospital locations within one single hospital organisation.

New possibilities in the field of medical technology (minimal invasive therapy), developments in ICT(telemedicine: monitoring and diagnostics at a distance using telecommunication technology) and furtherdevelopment of (transmural) care chains for specific patient groups are expected to result in new forms.

2 In the follow-up feasibility study on distribution of hospital care, part one (Netherlands Board for Hospital Facilities14 January 2002), as well as the Minister’s standpoint on this study (1 February 2002), these forms are explained infurther detail.


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3.5 Design of the general hospital building guidelines

The guidelines were drawn up on the basis of the different activities that take place in a hospital. In thefirst place these are activities that concern the primary process, in other words the direct interactionbetween the patient and the care provider (nursing, diagnostics and treatment). In addition there areactivities that have no direct relationship with the primary process, but are mainly focused on providingsupport and services in a general sense.Translated into spatial facilities, these different activities may be subdivided into three ‘blocks’:

A. patient-related facilities where the patients themselves are/may be present;B. patient-related facilities where patients themselves are not present;C. general & technical support services.

It should be added that this subdivision is not a blueprint for the way in which a hospital should bedivided up, but merely forms a plan based on the different activities within a hospital.

A. Patient-related facilities where the patients themselves are present

Three main function groups may be distinguished within this ‘block’ as follows:• nursing;• diagnostics & treatment;• special functions (in so far as these are present).

The nursing main function group includes the spatial facilities for special care, general nursing,paediatric nursing, maternity nursing (including delivery rooms), geriatrics and day nursing. However, inview of the nature of the care provided, the day nursing could also be placed under the main functiongroup diagnostics & treatment, non-specific. From the assessment experience of the Netherlands Boardfor Hospital Facilities, however, the day nursing unit appears in most cases to (still) form part of, or besituated in the close vicinity of the facilities for nursing.

The diagnostics & treatment main function group includes the following spatial facilities: outpatientappointment department, general organ function investigations, imaging diagnostics, nuclear medicine,outpatient treatment, operation unit, emergency unit and physiotherapy.

The special function main function group includes the spatial facilities for dialysis, a rehabilitation daytreatment unit or a radiotherapy unit.

B. Patient-related facilities where patients themselves are not present

This ‘block’ includes the spatial facilities for central sterilising services, the pharmacy and thelaboratories (clinical chemistry, medical microbiology, clinical pathology).

C. General & technical support services

This ‘block’ includes general and staff facilities (such as central kitchen, linen service, restaurant andtechnical service), as well as facilities for management and training.

There is a trend towards outsourcing some of the facilities listed under B and C to third parties. This isparticularly the case with the laboratories and pharmacy, administrative tasks, kitchen facilities, linenservice and technical service.

Based on examples from the consultancy experience of the Netherlands Board for Hospital Facilities,the table below shows (as an indicative average) what the share in percentage terms of the different


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blocks is of the floor area on the basis of the usual function package3 of a general hospital. Theexamples concern initiatives as currently being developed within the framework of the “new style”hospital.

(main) function group Share as percentage

Standard package

Block A: patient-related facilities (patient present) 65%

Block B: patient-related facilities (patient not present) 10%

Block C: general & technical (non-patient-related) services 25%

Total 100%

3 Excluding special functions


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4 BASIC QUALITY REQUIREMENTS

4.1 Introduction

By analogy with the subdivision in the National Building Decree, the basic quality requirements aredescribed at different levels: the location, accommodation, conditions (including hygiene) and safety &security.In these guidelines, the basic quality requirements are described at the level of the location(s) and thebuilding structure situated there, and take the form of “open standards” in line with the provisions in§ 2.1.Where the conditions are concerned (mainly hygienic aspects and special climatic requirements), pleaserefer to the building guidelines for indoor environment and building-related installations of theNetherlands Board for Hospital Facilities. For safety & security, please refer to the regulations of thirdparties, such as the National Building Decree and the Working Conditions Act. Any additional ordeviating basic quality requirements at both of these levels are described in the specific buildingguidelines.

In the specific building guidelines, further basic quality requirements are formulated for the relevanthospital functions within accommodation (building structure). These are more in the nature of “closedstandards”, in line with the provisions in § 2.1.

The basic quality requirements formulated below at the level of the hospital as a whole and the basicquality requirements as incorporated in the specific guidelines form the complete set of basic qualityrequirements with which building plans for new hospitals have to comply.

4.2 Reachability

• A general hospital should be easily reachable by public transport, assessed on the basis of transportfrequency and the distance to the stop, and also by taxi, car or bicycle.

Generally speaking, this requirement is complied with if a general hospital is situated at one of thegeographic/demographic concentration points in its catchment area. A geographic/demographicconcentration point is a municipality where the population level and level of amenities (schools, retailtrade, recreation, public services) is such that a substantial proportion of the population in the catchmentarea of the hospital is more or less automatically orientated towards that municipality.

4.3 Access

• The site needs to be easily accessible by patients, visitors and staff.

In this connection, specifications apply to pavements/ footpaths (minimum width, minimum free height,maximum slope, maximum height of kerbs), ramps (minimum width, maximum slope and length, halfwayand end platforms), outside stairs (minimum width, maximum rise, installation, height and design ofhandrails), material properties of paving surfaces (flat, rough and jointless) and lighting.Regulations also apply to the measurements and layout of parking places.

There are additional requirements for the less able, such as the size of parking places and the height ofparking meters. Obstacles should be indicated by warning paving, continuous guiding lines must bepresent.

• Taxis should be able to come right up to the main entrance and the entrance to the outpatient unit.


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• The entrance to the emergency department and if necessary the main entrance should beaccessible by ambulance.

• Public entrances to a hospital building should comply with minimum dimensions and also beaccessible by people with a physical handicap. These entrances should be covered over andprovided with good lighting.

• There are also specifications that apply to the entrance hall (sheltered situation, minimumdimensions, location of the doors, lighting), thresholds (maximum heights) and door handles. In thecase of revolving or carrousel doors, there must be an extra swing or sliding door provided.

Where main traffic areas are concerned, specifications apply to e.g. minimum width, free access height,the direction in which doors open, the presence and dimensions of rails along the walls and lighting.The same applies to internal stairs, which have to comply with specifications concerning the maximumrise and the minimum tread and for halfway landings.Where lifts are concerned, specifications apply for example to cage dimensions and access height andwidth (depending on the type of lift), the location of the operating elements and rails, and the manoeuvrespace in front of the lift door.

For further specifications, please refer to the Building Access Handbook and the Guide to theAccessibility of Buildings in the Healthcare and Social Services Sectors.

4.4 Flexibility

The concept of flexibility refers to the degree to which a building is adaptable to changing space needs.Flexibility is important in the healthcare sector because we are concerned here with a structural processof change. As a result of this, spatial adaptation of buildings in this sector is inevitable. With a high levelof flexibility, these adaptations can be kept to a minimum, as a result of which the financialconsequences and the hindrance to management – both in terms of building nuisance and spatial andorganisational disintegration – remain within acceptable levels.

• The main structural design of a hospital should possess a high degree of flexibility. The buildingstructure should be simple to extend at different points and should be able to cope with internaldisplacement.

A general hospital is a complex building with many rooms, the functional interpretation of which is highlyvaried. A characteristic feature of today’s hospital architecture is that account was taken of futurechanges and innovations in science, technology and policy when selecting the building structure.Over the years, various architectural concepts have been developed in which flexibility is an importantbasic criterium. In the past, the pavilion and Breitfuss models were among the most common usedstructures for hospitals. From the time that flexibility aspects started to play a role, new structuresappeared such as the comb structure, cross structure, linear structure and variations on thesestructures.

There are four types of flexibility, as follows: usage flexibility, disposal flexibility, layout or internalflexibility and extension or external flexibility4.

Usage flexibilityUsage flexibility concerns the possibility of changing the use made of a room/space without the need torenovate that room/space.

Disposal flexibility

4 Nicolaï, R. and Dekker K.H.: Flexibility as a building strategy for changing healthcare. Utrecht 1991.


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Disposal flexibility concerns the possibility of removing building elements without a detrimental effect onthe cohesion of the building elements to be retained and with a minimum of hindrance.

Internal flexibilityThe term internal flexibility refers to the possibility of interchanging hospital functions independent of thesupporting structure. A supporting structure with concrete columns makes this possible because theinternal fittings geared to the function can be removed without constructional consequences and bereconstructed once again. The possibilities for internal displacement are positively influenced bysituating “hard” hospital functions (where specific conditions are laid down regarding equipment andinstallations) next to “soft” hospital functions (with standard conditions with respect to equipment andinstallations). The hard hospital functions can in this way displace the soft hospital functions, therebysafeguarding future growth.The “soft” hospital functions act in fact as buffers. One condition for these buffers is that the relevantfunctions should not place high technical demands on the building and that their location is not of majorimportance from an organisational point of view. Consequently, displacement of these functions shouldnot form any great problem.

External flexibilityThe term external flexibility refers to the possibility of expanding the existing building structure.Expansion possibilities are mainly programmed for functions where growth may be expected. In thedesign, it is assumed that after the extensions have been carried out, the functionality of the wholebuilding will be guaranteed. For example: possible extensions will need to link up in a logical way to theinternal traffic system and to the main infrastructure of the installations.When planning the hospital functions in relation to each other, it is also possible to obtain a flexiblydesigned hospital. An example of this is a building structure where functions that do not form part of theprimary process are placed in separate building elements. The nursing, diagnostic and treatmentdepartments are concentrated in the main core of the hospital. The pharmacy, laboratories, storeroomsand the kitchen are located in service buildings at a distance from the main core.

4.5 Spatial relationships

The demands placed on spatial relationships between the different components of a hospital in thearchitectural design are based on two elements. On the one hand requirements are formulated that arederived from medical and logistic factors that are independent of the chosen organisational form of thehospital. On the other hand, the spatial relationships are determined by the organisation of the hospital,for which 3 possibilities have been outlined in chapter 3.

It may be necessary to lay down proximity requirements for different parts of a hospital on the basis ofmedical or logistic arguments. These requirements are based on the different activities taking place in ahospital and are separate from the requirements that can be formulated on the basis of the organisationof the hospital. These activities are not dependent on the organisational form of the hospital.Requirements based on medical arguments concern primary proximity requirements that are laid downbecause fast transport is essential in the interests of the patient. A primary proximity requirement iscomplied with if there is a direct link in a horizontal or vertical sense between two function groups ordepartments of a hospital. Use can be made here of a lift with pre-selected control. A primary link of thiskind is essential between on the one hand the emergency unit and on the other hand the operating unit,the imaging diagnostics unit and the location where emergency treatment is given to heart patients. Aprimary link is also necessary between the operating unit and the intensive care and obstetric units.Proximity requirements as a consequence of logistic factors are based on the volume of patient,personnel or goods traffic between the different elements that form the hospital. The proximityrequirements arising from this aspect are subordinate to the primary proximity requirements based onmedical factors. It is worth recommending that the facilities to be used by outpatients should be situatedso as to be easily reachable in relation to each other. This particularly concerns the outpatient


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appointments desk, facilities for organ function investigations, the hospital laboratory and the imagingdiagnostics unit. Requirements can also be laid down in connection with the volume of goods transport.As a rule, the operating unit and the central sterilising services unit are usually located so as to makethem easily reachable from each other.

On the basis of the type of organisation chosen by the institution (see also chapter 3), spatialrequirements can be formulated between the different components of the organisational units andbetween these units themselves. The relationship requirements arising from the organisational form aresubordinate to the primary relationships formulated above. It is worth recommending, for the sake ofcohesion, that the chosen organisational form should be expressed in the spatial structure.

4.6 Quality of the environment

The quality of the built external and internal environment of hospitals not only has an impact on the well-being of the care providers, but also on the healing process and behaviour of patients. This has beenshown by the many studies that have been carried out in this field in recent years.The results of these studies have led to increased attention being paid to the psychological impact ofenvironmental aspects of healthcare institutions, including hospitals. In addition, attention is increasinglybeing focused on the role of the patient in healthcare.

Studies have shown that the well-being of patients and visitors is promoted by an environment that:

• is easy to reach and where everything can be clearly found: for example a clearly recognisablemain entrance and good signposting inside the building;

• is comfortable and increases autonomy. The use of materials, colour and art play a role here;• promotes the relationship with nursing staff: for example by the right location of the nursing station

on a ward and the presence of an adequate nurse call system;• provides confidence and privacy, both visually (for example no undesirable views from the corridor)

and acoustically (for example by use of sound absorbent materials and locating mainly quietfunctions next to patient rooms);

• pays attention to relatives: for example facilities for visitors such as chairs in patient rooms,possibilities for rooming in (children’s ward) and resting facilities should the presence of relatives benecessary outside visiting hours;

• provides contact with the outside world: for example by making means of communication available(radio, tv, telephone) and providing a clear view outside;

• is safe, secure and bright: for example by ensuring that sufficient daylight can penetrate, by usingnon-institutional furnishings and lighting and avoiding long, obscure corridors.

The Netherlands Board for Hospital Facilities is planning to develop a tool based on the concept of theEnglish AEDET method that endeavours to objectify the assessment of the above-mentioned aspects. Itis the intention for the institutions themselves to be able to use this tool.


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5 ARCHITECTURAL CONCEPTS

5.1 Introduction

This chapter gives a few striking examples of hospitals that have either already been built or are in theprocess of development. Examples are provided of each distinctive type of building. However, the factthat these examples have been included here does not mean that a new hospital necessarily has to bedesigned on the basis of one of these models. The examples show how concepts such as flexibility,functional relationships and design were translated in the relevant period or are currently beingtranslated into the building structure of the hospital.The following models will be dealt with:− the Breitfuss model− the double comb structure− the arcade model− the cross structure− the branched structure− the linear structure− the pavilion structure

The building structure of a hospital has undergone a development that shows a decreasing dominanceof the ward block. The treatment and outpatient departments and the flexibility and design of the maintraffic areas have had an increasing impact on the main design of the hospital. Post-war hospitalbuilding in the early decades generated many hospitals with imposing, sometimes monumentallydesigned ward blocks. In the eighties, when flexibility became an important concept, more neutrallydesigned hospital structures evolved. Subsequent developments show a more internally-oriented designof the buildings, through the use of covered streets and plazas. Recently developed hospital designs arecharacterised on the one hand by more emphasis placed on the design. On the other hand, sincehospitals have been increasingly built in an urban context due to land problems, fitting them into theurban environment has become an important concept.


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5.2 Breitfuss model

generalA typical feature of the Breitfuss model is that a tall building block with nursing functions is placed abovea flat building block with treatment and outpatient functions. The structure of the building shows a cleardivision between the static nursing units in the ward block and the dynamic departments on the lowertwo (or three) storeys. The external appearance of the ward block is often of an imposing design due toits definitive status.

accessIn general it may be said that the Breitfuss model produces a compact building with relatively shortwalking distances. However, staff and visitors do have to make frequent use of the lifts. The number oflifts is partly determined by the number of storeys of the ward block. In the case of highrise with around10 floors, a considerable part of the ward block will be taken up by provisions for vertical traffic (lifts and(emergency) staircases).Due to its compact design, this model usually has a clearly recognisable main entrance.

functional relationshipsSince the lowrise structure contains all diagnostic and treatment functions, it is possible to create goodspatial relationships with this type of building. Where the medical staff is concerned, the stacking of thewards can mean that there is a considerable distance between the outpatient unit and the wards.The Breitfuss model, originally designed according to functional planning of the care provided (outpatientappointment unit, nursing unit, imaging diagnostics, laboratories, etc.), offers in principle sufficientpossibilities for planning the facilities for care provided on the basis of patient flows or on the basis of thecare process (see § 3.3). The Breitfuss model is less suitable for planning on the basis of target-groups.

flexibilityWhere flexibility is concerned, account has only been taken of the possibility of adaptation andexpansion in relation to functions on the lowest floors. No possibilities for expansion or adaptation haveusually been provided for in the ward block. As a result of these limitations in the design, it is moredifficult with this type of building to comply with policy concerning the new style hospital that advocates ashift from inpatient to outpatient.


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example of Breitfuss modelLocation and name of institution The Hague – Leyenburg Hospitaldate of completion 1971number of beds 750 bedsgross floor area 90,000 m²

5.3 Double comb structure

generalThe double comb structure is characterised by a traffic zone in the centre from which different buildingwings protrude like the teeth of a comb. The building structure is designed like a uniform grid. Itcomprises many end walls, the so-called “open ends”, which make it simple to add extensions.

accessDue to the many open ends, the external architecture gives the impression of being unfinished. Incontrast with the Breitfuss model, for example, an overall picture of the hospital is not visible. If locatedin the heart of the traffic zone, the main entrance may be hidden between the teeth of the comb.In the case of large hospitals, this structure can lead to a sprawling design.


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functional relationshipsFunctions which have to comply with the same requirements are grouped in one wing. From the point ofview of size and technical requirements, the teeth of the comb are geared to the functions to be housedthere. Practical experience has shown that stacking spatially related functions with specific requirementsregarding installations can also be successfully done in one wing. For example, the emergencydepartment is located on the ground floor, intensive care on the first floor and the operating unit on thesecond floor. Other designs may include all laboratories in one wing, plus the pharmacy and the centralsterile supply services unit, or wings with only nursing functions.The double comb structure is in principle suitable for all three planning models described in § 3.3 withregard to accommodating the care organisation.

flexibilityThe double comb structure was developed at a period when flexibility had become one of the mostimportant design criteria. Flexibility is guaranteed by extending the teeth of the comb or by extending thetraffic structure by adding a new wing. The basis structure of the hospital remains unchanged after theseextensions.

example of double comb structurelocation and name of institution Nieuwegein – St. Antonius Hospitaldate of completion 1979number of beds 579 bedsgross floor area 61,000 m²


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5.4 Arcade structure

generalThe arcade hospital emerged as a new model in the early eighties and has been used a number oftimes in the Netherlands. In this model, the building elements of the hospital are linked with each otherby a glass-covered arcade for main traffic. Located on both sides of this arcade, on several floors, arethe rooms or internal access routes that look out onto the arcade. In the arcade on the ground floor are anumber of public amenities such as shops and a restaurant.

accessThe high arcade is a clear structuring element. The main entrance at one end of the arcade is easilyrecognisable. From the arcade, the vertical means of access to the upper floors are clearly visible.

functional relationshipsIt is evident from the hospitals built in accordance with this model that organisation can take place invarious different ways.In Waterland Regional Hospital in Purmerend, the functions are located above each other. On theground floor are the outpatient clinics, on the first floor the operating department and the laboratories,and above those a technical floor. The top two storeys house the nursing wards.In Almere, Flevo Hospital is also based on an arcade model, but in this instance the functions have beenplaced behind each other in different parts of the building. The outpatient departments, imagingdiagnostics and the accommodation for management functions are situated near the main entrance. Inthe centrally located areas of the building are the operating department, the emergency department,laboratories and physiotherapy. At the end of the arcade are two building elements containing thenursing wards.

Maasland Hospital in Sittard, currently at the design stage, will also be built according to the arcadestructure. A section of the building for treatment functions is planned in the heart of the complex, at rightangles to the arcade. Parallel to the arcade on the ground floor and the first floor will come the outpatientdepartment facilities. Above these, on the top three floors, will be the nursing wards.

The arcade structure is in principle suitable for all three planning models described in § 3.3 with regardto accommodating the care organisation.

flexibilityIn a similar way to the double comb structure, the traffic structure (arcade) can be extended whileretaining the basic structure and new building elements can be added to it. The building elements linked


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to the arcade usually have open ends on the other side that make it simple to add extensions in thefuture.

example of arcade structurelocation and name of institution Almere – Flevo Hospitaldate of completion 1991number of beds 213 bedsgross floor area 19,000 m²

5.5 Cross structure

generalIn the case of this model, two building blocks each in the form of a cross have been linked to each otherso as to create a large covered hall between the two building blocks. The covered hall is the centre ofthe building and contains the central facilities.


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accessThe main entrance is located in on corner of the covered hall. This plaza is the heart of the structure andcontains the central facilities. The vertical access points in the cross-shaped building blocks are clearlyvisible from the plaza. This structure lends itself well to the development of a relatively large hospitalwithin a compact design.

functional relationshipsThe best-known hospital based on this model is the Rijnstate Hospital in Arnhem. Virtually all thenursing wards are housed on the top four storeys of this hospital. The outpatient departments andtreatment & diagnostics units are located on the lower level. Between the upper and lower level is atechnical floor. From the two intersections, a walkway diagonally crosses the central hall at a first floorlevel, thereby reducing walking distances. The cross structure is in principle suitable for all threeplanning models described in § 3.3 with regard to accommodating the care organisation.

flexibilityThe open ends of the cross-shaped building sections can be extended while retaining the basicstructure.

example of cross structurelocation and name of institution Arnhem – Rijnstate Hospitaldate of completion 1994number of beds 750 bedsgross floor area 82,000 m²


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5.6 Branched structure

generalUnder the heading branched structure, a look will be taken at two completed hospitals where the mostcharacteristic element of the structure is formed by the number of branches and open ends. Thisconcerns the Canisius Wilhelmina Hospital in Nijmegen completed in 1992 and the Antonius Hospital inSneek completed in 1994. In both of these hospitals, a square central hall forms the heart of thebuilding.

accessThe main entrance is directly linked to the central hall. The central hall is the centre of the structure andcontains amenities such as boutiques and a restaurant. From this central hall the patients and visitorscan gain access to the most important departments of the hospital. The main stairwells and the lifts areeasily accessible from the central hall.

functional relationshipsThe Canisius-Wilhelmina Hospital in Nijmegen was built according to this design.With an average of 3 storeys, this hospital is relatively lowrise. The outpatient departments have theirown entrance, but this is located on the same side of the square as the main entrance. Most nursingwards are located in the branches leading off the square. The operating department and intensive careare situated on the top floor. The situation and size of the site made it possible to build a relativelylowrise hospital. This means that all the wards have a pleasant view over the green surroundings.The Antonius Hospital built in Sneek is also characterised by lowrise building. In this hospital, separatebuildings elements were developed per main function. The services building is located separately sothat this function can respond to future developments. Functions which require a higher building heighthave been located on the top floor. This concerns the X-ray and operating departments, physiotherapy,pharmacy and laboratories.A branched structure is in principle suitable for all three planning models described in § 3.3 with regardto accommodating the care organisation.

flexibilityDue to the existence of many open ends, a branched structure possesses by definition sufficientexternal flexibility. The following observations may be made regarding flexibility in the Antonius Hospital.The different function groups have been housed in separate building elements with a construction andraster size geared to the function group. Supporting outside walls have been used for patientaccommodation, while diagnostic, treatment and service functions have a skeleton structure. Since each


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main function is located at an open end, the possibility of expansion is guaranteed. All beds in the multi-bed rooms are of equal quality due to the fact that the beds are located by a window. In addition, allmulti-bed rooms can be partitioned into maximum one-bed rooms.

example of branched structure

location and name of institution Sneek – Antonius Hospitaldate of completion 1992number of beds 270 bedsgross floor area 29,000 m²


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example of branched structurelocation and name of institution Nijmegen – Canisius-Wilhelmina Hospitaldate of completion 1992number of beds 638 bedsgross floor area 63,000 m²

5.7 Linear structure

generalFor the draft plan for Vlietland Hospital in Schiedam, a design has been developed consisting of a singlelinear block that can accommodate all hospital functions in accordance with their inter-relationships. Thedepth of the block is approximately 22 metres and is designed for the application of a double corridor.Stairwells and cable and piping shafts have been incorporated in a rational design in the central zone.


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accessThe linear block forming the hospital is designed with a number of kinks so that the overall shaperesembles a hairpin. An entrance is located on both sides and opens into a high glass hall that iswedged between the linear building block. The different lifts and stairwells can be reached from thecentral hall. In places where a short link is required for functional purposes, additional glass connectioncorridors have been designed between departments located opposite each other. In this way acceptablewalking distances have been achieved.

function relationshipsThe dimensions of the linear building have been geared to house both outpatient clinics and nursingwards. On different floors, outpatient departments are located next to nursing wards. In the case offuture bed reductions, wards can easily be converted into outpatient clinic space. This design is fully inaccordance with policy on new style hospitals where a shift from inpatient to outpatient is advocated.

flexibilityThere are limitations regarding the external flexibility of the design of Vlietland Hospital on account of thefact that it only has two open ends and due to the size of the site. Internal flexibility is good, due forinstance to the rational uniform design which makes it possible to interchange functions.The linear structure is in principle suitable for all three planning models described in § 3.3 with regard toaccommodating the care organisation.


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example of linear structurelocation and name of institution Schiedam – Vlietland Hospitaldate of completion 2006 (planned)number of beds 453 bedsgross floor area 48,000 m²

5.8 Pavilion structure

generalDuring the pre-war years, larger hospitals were built according to the pavilion structure. A cluster ofcategorial hospitals was built on the site. This method was abandoned after the war. Today, however,some designs for large hospitals are returning to the pavilion structure and opting for a plan according toclinical entities, themes or type of care. An example of this is the design for the Isala Clinics in Zwolle. Acharacteristic feature of the pavilion structure is that the spatial facilities that form part of the chosen planare grouped together.


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accessThe design of the new building for the Isala Clinics comprises four blocks, varying from four to sixstoreys. Each block has an atrium. The building blocks will be built on three sides of the existingcomplex. Situated beneath the new building blocks is a parking garage from which all four blocks can bereached. In addition, the main entrance is located between two blocks, passing into a central hall intowhich opens an extensive system of corridors providing access to all the building elements. This designhas several different entrances as a result of which extra measures will be necessary from the point ofview of security and surveillance.

functional relationshipsThe new building will house virtually all patient-related functions, organised per block according toclinical entity. As you move higher up the building, facilities for outpatients decrease as inpatient facilitiesincrease.The pavilion structure is particularly suitable for a plan based on care according to target-groups/clinicalentities.

flexibilityA design based on planning according to clinical entity in one or more building elements has a negativeeffect on flexibility. Changes in activities and space between the functional units as a result ofdevelopments in the care sector will be difficult to achieve in the future without a change in the basicorganisation principles.

External flexibility does exist, however, since in this design a number of building elements can beextended at the ends. Account has also been taken of constructing an extra floor on top of the differentbuilding elements.


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example of pavilion structurelocation and name of institution Zwolle – Isala Clinicsdate of completion last section 2011 (planned)number of beds 911 bedsgross floor area 126,000 m²


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6 FINANCIAL ASPECTS

6.1 Investment costs framework for new buildings

This chapter shows how the maximum investment costs can be determined on the basis of the currentlyapplicable Annual Note on Building Costs. The investment costs comprise three components: the directand building-related costs, the cost of the land and the starting costs.Inventory costs for a general hospital are not assessed within the framework of the Hospital ProvisionAct (WZV).

The investment costs framework for a hospital is determined by two quantities: the normative floor areaand the building costs per m².Indicators have been included in the Building Standards Regulations for both quantities. Until now theapplicable floor area standard figure for hospitals, on the basis of which the normative floor area iscalculated, has been linked to the bed parameter. This parameter, which is exclusively based on theinpatient flow, takes insufficient account however of the reduced use of beds in hospitals as a result of ashift from inpatient care to outpatient care and day nursing.

On 26 November 2001, the Netherlands Board for Hospital Facilities advised the Minister in an alertreport to drop the bed parameter and change to an ‘adherent inhabitant’ parameter, and in addition tothe inpatient flow also allow the outpatient flow to be a determining factor for calculation of the normativefloor area of a hospital.In the new calculation method, a market share will be determined per patient flow (inpatient andoutpatient adherency) that will be projected on the future population in 2010, leading to the futureadherency per patient flow of the hospital. In addition, this future adherency per patient flow will bemultiplied by a normative floor area per patient flow (inpatient: 162 m² per 1,000 adherent inhabitants,outpatient: 104 m² per 1,000 adherent inhabitants).The normative floor areas per patient flow calculated according to the method together form the totalnormative permissible floor area for the normal function package of a general hospital.In some cases, the general hospital also has special functions for which the space requirements can bedetermined with the help of supplementary floor area indicators adopted by the Netherlands Board forHospital Facilities on 7 October 1996 (recommendation concerning capacity parameters article 18Hospital Provision Act) and on 18 November 1996 (recommendation concerning other PM items relatingto space requirements standardisation).

The investment costs framework for a new building intended to completely replace a hospital willsubsequently be determined by multiplying the total gross floor area (normal + specific functions) by thebuilding price per m² for a hospital as incorporated in the Annual Note on Building Costs of theNetherlands Board for Hospital Facilities5.

5 As long as the Minister has not yet agreed to the new calculation method given in the Alert Report “Method ofcalculating normative floor area; alternative to the bed parameter” (Nov. 2001), the floor area calculation based onthe bed parameter continues to apply (see also the aforementioned alert report ).


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By way of illustration, an investment costs framework is determined in the table below on the basis of afictitious example.

Gross floor area

Inpatient

162 m²/1,000

inhabitants

Outpatient

104 m²/1,000

inhabitants

Total

Standard package

Inpatient adherency 150,000 inhab.

Outpatient adherency 160,000 inhab.

Total

24,300 m²

16,640 m²

40,940 m²

PM items 3,000 m²

Total floor area 43,940 m²

Building price per m² *)

Total investment costs framework

€ 2,212.-

€ 97.2 mln

*) Source: Annual Note on Building Costs 2002, incl. VAT, price level 1 Jan. 2001, exclusive land, inventory andstarting costs

Please refer to the provisions in the Annual Note on Building Costs for land, inventory and starting costs.

6.2 Practical application

Given the investment costs framework, a hospital organisation has the freedom to develop the requiredarchitectural care infrastructure as it sees fit. Occasionally, for example in a multi-location model or inorder to facilitate transmural cooperation with other care facilities (eg general practitioner centre,convalescent unit), a hospital organisation can create more floor area within the framework forinvestment costs than is permitted within the calculation method norms.Conversely, a hospital organisation can opt to create less floor area than would be permitted accordingto the calculation method norms and to use the investment costs that hereby become free to financeadditional investments in ICT for example. It should be added here that if the reduction in the floor areais a result of outsourcing specific services (see § 3.5), the framework for investment costs will bereduced accordingly, in line with the CTG (National Health Tariffs Authority) policy regulation on capitalcosts when outsourcing.

The mechanism described above is applicable one to one in cases of new building development that isintended to completely replace a hospital organisation.In situations where this is not the case, such as large-scale concentrated building adjoining an existinghospital location that has to be renovated, determination of the investment costs framework takes placeas follows. In the first instance, the standard permissible floor area of a hospital organisation iscalculated on the basis of the method described in § 6.1. You then take a look at the size of the internallayout losses of the existing hospital location, on the basis of which it can be determined how many m²of new building or renovation will be provided for. The size of the new building is multiplied by thebuilding cost per m² for a hospital as stated in the Annual Note on Building Costs, while the investmentcosts for the renovation depend on the physical-functional and technical installation state of the buildingat the existing hospital location as well as the projected functions.


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The building cost per m² stated in the Annual Note on Building Costs concerns an average price per m²that includes both expensive m² (for example for the operating department, laboratories) as well ascheap m² (for example for office-type facilities). In the specific standards with basic quality requirementsthere are differentiated cost norms for the relevant functions. These differentiated cost norms can beused as a basic criterium in situations where a hospital organisation is only intending to put up a newbuilding for a specific hospital function.

Hospital Design Guidelines

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