How life beats in a structure: Morphology and design doctrines of contemporary hospitals in Bangladesh

--Ar. Shabab Raihan Kabir

6. shabab 02

When I was young I had to visit the hospital where my father was admitted after a stroke due to hypertension.  To cut a long story short, my father had to have about 5 minor and major operations to repair his broken health. From that day on, and for a long time to come, I was petrified on the mere sight and smell of all things of hospital. Does this sound or feel well-known? I bet it strikes a chord with a great majority of you.

Health is collectively regarded as an important manifestation of human development. The Constitution of the People’s Republic of Bangladesh ensured that “Health is the basic right of every citizen of the Republic” as health is elementary to human development. Since independence Bangladesh has ended noteworthy progress in health outcomes and the government has been pursuing a policy of health progress that ensures prerequisite of basic services to the entire residents, particularly to the under-served inhabitants in rustic areas. Within the overall development policy framework of the Government of Bangladesh, the goal of the health, nutrition and population (HNP) sector is to achieve sustainable improvement in health, nutrition and reproductive health, including family planning status of the people, particularly of vulnerable groups, including women, children, the elderly, and the poor with the ultimate aim of their economic emancipation and physical, social, mental and spiritual well being. Three sub-sectoral policies, i.e., National Health Policy, National Food and Nutrition Policy, and National Population Policy duly approved by the government from time to time are under execution by the MOHFW. Non Government Organizations (NGOs) are significant and growing sources of HNP services in both rural and urban Bangladesh. Their services have mainly been in the areas of family planning and MCH. More recently, NGOs have extended their range of services and are now the major providers of urban primary care.

The Basic 5 steps of hospital planning

How do we go about setting up a hospital?  The hospital, big or small, all hospital services will require the same 5 steps loom:

Step 1:  Project Conceptualization:  This is the beginning stage where one is trying to visualize his / her hospital in terms of its ownership, philosophy, bed-mix, facility-mix, etc.  This requires responsibility at the very least a fundamental but inclusive research of the physical, geographic surroundings of the proposed area. This information can be obtained through the web, current and archived newspaper mentions, municipality reports, and then undertaking a short survey or holding focus group discussions.  The basic idea is to comprehend the gaps in the medical market in that area and intend to fulfill them, unless of course, the owner is a Doctor entrepreneur, who knows exactly what he wants.

Step 2: Feasibility Analysis:  When the project concept in understood, settled on and locked-in, the subsequently is to understand the viability of the proposed hospital.  This would mean commission a detailed working of at least the following:

Project Cost:  Comprising of civil work, medical equipments, furniture and fixtures, professional fees, interest during construction, pre-operative expenses and contingency expense appropriations.

Sensitivity Analysis:  This is the most significant part generated for the project and helps the developer to undertake a “go or no go” decision. It also identifies the financial limitations of the proposed project and frequently helps the developer to structure the means of financing the project.  It’s important to note here that all assumptions should be made with a realistic view.

Step 3: Hospital Designs:  Hospitals are highly engineered buildings, so this step requires a meticulous attention to micro details.  For this reason alone, it’s vital that one hires a competent team of designers, which would include an architect, a structural consultant, an electrical consultant, a plumbing consultant, an interior designer consultant, a landscape consultant, etc.  The emphasis should be a building which does its job brilliantly, more functional than glamorous.  The focal point of this exercise should be to ensure that energy efficiency, natural light and ventilation and ease of maintenance get all the special attention they need. Always remember that the highly engineered buildings cost more.

Step 4:  Project Management:  The thought that an architect is automatically a good Project Manager is a myth, it should not be very difficult to understand that the architecture should effortlessly accommodate the complexities of engineering services and the installation of very sophisticated, very costly medical equipment – apart from the various financial and speed of work related issues involved in project execution.   It is extremely important to have a separate project management entity to ensure that the final designs are executed as per what was envisaged.  All tendering activities, quality of construction, managing change of design midway, site safety and bill certification periodically are some of the vital aspects of project management.

Step 5:  Commissioning the Hospital:  The last step of hospital project is to complete it for accepting patients and starting all operations.  This process should begin at least 6 to 9 months prior to inauguration as there are a plethora of activities  to be completed before the patient walks in, issues like developing personal policy, salary structure, standard operating procedure for all department selecting and customizing hospital information system, recruitment, trial runs of equipments, stationary, designs, etc.  It is generally easier to put up the hardware, but the success of the project will depend on how the software bit of commissioning the hospital is handled. It throws light on how best to set up a Healthcare facility.

One of the successful policies in health sector rectification in Bangladesh is Drug policy which was promulgated in 1982 intended to remove medicine considered harmful, useless and unnecessary from the market and ensures the supply of essential drugs of all levels of health care delivery, at affordable price. Bangladesh had shown commendable development in the pharmaceutical sector following successful implementation of the National Drug Policy 1982. To achieve the Millennium development Goals (MDGs) – improvements in some health indicators have been remarkable, especially in reducing fertility, reducing under 5 mortality, providing vaccines to children and mothers, reducing vitamin A deficiency, and others. In other areas the country is lagging behind and more must be done and coordinated effort will be needed to ensure that the promise of the MDGs is realized.

In the face of being a resource poor country, Bangladesh has achieved remarkable health gains which formulate it an example for other developing countries. Over the last decades key health indicators like life expectancy and coverage of immunization have improved significantly while infant mortality, maternal mortality and fertility rates have dropped considerably. But most of these achievements are mainly quantitative while qualitative improvement is negligible. Poor access to services, low quality of care, high rate of maternal mortality and poor status of child health still remain as challenges of the health sector.

National Health Policy of Bangladesh

Goal and objectives of the national health policy:

First: To make necessary basic medical utilities reach people of all upazilla as per Section 15 (A) of the Bangladesh constitution and develop the health and nutrition status of the peoples as per Section 18 (1) of the Bangladesh Constitution.

Second: To develop system to ensure easy and sustained availability of health services for the people, especially the poor communities in both rural and urban areas.

Third: To ensure optimum quality, acceptance and availability of primary health care and governmental medical services at the upazilla and union levels.

Fourth: To reduce the intensity of malnutrition among people, especially children and mothers; and implement effective and integrated programs for improving nutrition status of all segments of the population.

Fifth: To undertake programs for reducing the rates of child and maternal mortality within the next 5 years and reduce these rates to an acceptable level.

Sixth: To adopt satisfactory measures for ensuring improved maternal and child health at the union level, and install facilities for safe and hygienic child delivery in each village.

Seventh: To improve overall reproductive health resources and services.

Eighth: To ensure the presence of full-time doctors, nurses and other officers/staff, provide and maintain necessary equipment and supplies at each of the upazilla health complexes and Union Health and Family Welfare Centers (UHFWCs).

Ninth: To devise necessary ways and means for the people to make optimum usage of available opportunities in government hospitals and the health service system, and ensure satisfactory quality management, cleanliness of service delivery at the hospitals.

Tenth: To formulate specific policies for medical colleges and private clinics, and to introduce laws and regulation for the control and management of such institutions including maintenance of service quality.

Eleventh: To strengthen and expedite the family planning program with the objective of attaining the target of Replacement Level of Fertility.

Twelfth: To explore ways to make the family planning program more acceptable, easily available and effective among the extremely poor and low-income communities.

Thirteenth: To arrange special health services for the mentally retarded, the physically disabled and elderly populations.

Fourteenth: To determine ways to make family planning and health management more accountable and cost-effective by equipping it with more skilled manpower.

Fifteenth: To introduce systems for treatment of all types of complicated diseases in the country, and minimize the need for foreign travel for medical treatment abroad.

Medical Architecture Planning System

Health Services Organization:

Hospitals are the most multifarious of building types. Hospitals do not exist in a vacuum. They influence and are influenced by the manifold of demographic, epidemiologic, economic, and socio-cultural settings within which they operate. Focus will be given to the “healthcare organization system”. Referral patterns between the different types of healthcare facilities, e.g. health centers, general hospitals and teaching hospitals, will be examined. Each hospital is comprised of a wide range of services and functional units. These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental inpatient care or bed-related function. This diversity is reflected in the breadth and specificity of regulations, codes, and oversight that govern hospital construction and operations. Each of the wide-ranging and constantly evolving functions of a hospital, including highly complicated mechanical, electrical, and telecommunications systems, requires specialized knowledge and expertise. No one person can reasonably have complete knowledge, which is why specialized consultants play an important role in hospital planning and design.

The functional units within the hospital can have competing needs and priorities. Idealized scenarios and strongly-held individual preferences must be balanced against mandatory requirements, actual functional needs (internal traffic and relationship to other departments), and the financial status of the organization.

In addition to the wide range of services that must be accommodated, hospitals must serve and support many different users and stakeholders. Ideally, the design process incorporates direct input from the owner and from key hospital staff early on in the process. The designer also has to be an advocate for the patients, visitors, support staff, volunteers, and suppliers who do not generally have direct input into the design. Good hospital design integrates functional requirements with the human needs of its varied users.

The Architect should have an understanding of the healthcare system within which the hospital is being built. Otherwise he or she would be planning in a vacuum.

The basic form of a hospital is, ideally, based on its functions

l               bed-related inpatient functions

l               outpatient-related functions

l               diagnostic and treatment functions

l               administrative functions

l               service functions (food, laundry, supply)

l               research and teaching functions

Physical relationships between these functions determine the configuration of the hospital. Certain relationships between the various functions are required-as in the following flow diagrams.

These flow diagrams show the movement and communication of people, materials, and waste. Thus the physical configuration of a hospital and its transportation and logistics systems are inextricably intertwined. The transportation systems are influenced by the building configuration, and the configuration is heavily dependent on the transportation systems. The hospital configuration is also influenced by site restraints and opportunities, climate, surrounding facilities, budget, and available technology. New alternatives are generated by new medical needs and new technology.

In a large hospital, the form of the typical nursing unit, since it may be repeated many times, is a principal element of the overall configuration. Nursing units today tend to be more compact shapes than the elongated rectangles of the past. Compact rectangles, modified triangles, or even circles have been used in an attempt to shorten the distance between the nurse station and the patient’s bed. The chosen solution is heavily dependent on program issues such as organization of the nursing program, number of beds to a nursing unit, and number of beds to a patient room.

Morphology and Design Doctrines of Contemporary Hospitals

These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental inpatient care or bed-related function.

Hospital design has been subject to many changes over the past 100 years or so in both layout and size. In the early 20th century hospitals were basically places where the very sick spent their last days! Nowadays, emerging concepts of a hospital are calling for a design that promotes wellness and wellbeing rather than merely the treatment of diseases.

Hospital Programming

Before the Architect puts a line on the drawing board, he or she will formulate a detailed “Functional & Space Programs” for the proposed hospital project. The designer also has to be an advocate for the patients, visitors, support staff, volunteers, and suppliers who do not generally have direct input into the design. Good hospital design integrates functional requirements with the human needs of its varied users.

Functional Zoning

Hospital design is almost totally centered on their complex functional requirements. The form and layout of hospital facilities have to meet the criteria for sterility, segregation of workflow, un-obstruction of emergency routes, nurse observation, patient and staff safety, and many others. A basic principle in hospital zoning is “controlled movement”. Patients, staff, visitors and materials should move throughout hospitals according to certain criteria that meet the requirements to segregate soiled traffic form clean traffic. Another basic principle is functional proximities and relationships where certain department are required to be adjacent or close to other departments for reasons that relate to patient and staff movement, in both normal and emergency cases.

Hospital Space Programming

The hospital’s space and functional programs comprise the foundation for all subsequent design activity. A hospital can only be as good as its program. The hospital planner shall determine the number of all functional units in the project such as the number of operating rooms, outpatient clinics, Endoscopy rooms, as well as major equipment capacities such as CSSD equipment, laundry and kitchen equipment. In this section, the principle and methods of formulating the hospital’s space program will be presented. Participants will use automated applications to determine the space requirements of a hospital project based on international hospital planning codes.

Planning Inpatients Wards

Ward design has been subject to many changes over the past 50 years or so in both layout and size. The introduction of controlled mechanical ventilation systems into hospitals had prompted hospital planners to move away from the long and narrow “Nightingale Ward”. Increasing patients expectations (e.g. need for visual and audio privacy) have more recently prompted for private and semiprivate patient rooms and away from the larger capacity rooms (12-bed, 8-bed, 6-bed, and 4-bed rooms). The basics of ward configuration including parameters such as the number of beds per ward, nurse walking distance, patient room layout and options, will be discussed amongst other points.

Planning Outpatients Clinics

Outpatients Areas are the busiest of hospital areas. The principles and design concepts to streamline the patient traffic in the outpatients department will be examined with exemplary layout.

Planning The Operating Department

Perhaps of all other departments in the hospital, the surgical suite has been the most department studied and researched over the past 50 years or more. Many different options of the surgical suite layout have been proposed and used. The primary design criteria were to segregate the soiled form sterile traffic.

Planning the Delivery Department

The objective in planning the delivery suite is to recognize functional requirements with pleasant healing environments. If anyone department should be taken out of the hospital, it will most likely be the “Delivery Suite”, reason being that it is a place for family to rejoice the new born and not to recover from illness. The architect should design this department as homely as possible, without compromising clinical needs.

Planning Other Hospital Departments

In subsequent sections, the planning and design principles of other principal department in the hospital will be examined;

l               Emergency Department

l               Radiology Department

l               Endoscopy  Unit

l               CSSD

l               Pharmacy

Current Concepts in Hospital Planning

Healthcare organization, medical and pharmaceutical advances, and medical technology developments and patient expectations are continuously changing at a fact pace. The implications of these changes on the planning and design of response to them manifests itself in emerging planning concepts and ideas. In this section, some of these concepts will be examined and discussed.

l               Healing healthcare environments

l               Patient focused design

l               Patient hotels

l               The universal patient rooms

l               The digital hospital

Impact of Medical Technology on Hospital Planning and Design

Advances in medical technology are very fast paced. Their implications and impact on the design of hospital facilities will be discussed in this section. Technologies including digital radiology, endoscopic surgery, surgical robots among other advances will be examined and their impact on the hospital layout illustrated by recently built exams.

Building Attributes

Regardless of their location, size, or budget, all hospitals should have certain common attributes.

Efficiency and Cost-Effectiveness: An efficient hospital layout should:

l               Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces

l               Allow easy visual supervision of patients by limited staff

l               Include all needed spaces, but no redundant ones. This requires careful pre-design programming.

l               Provide an efficient logistics system, which might include elevators, pneumatic tubes, box conveyors, manual or automated carts, and gravity or pneumatic chutes, for the efficient handling of food and clean supplies and the removal of waste, recyclables, and soiled material

l               Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas, and by making prudent use of multi-purpose spaces

l               Consolidate outpatient functions for more efficient operation-on first floor, if possible-for direct access by outpatients

l               Group or combine functional areas with similar system requirements

l               Provide optimal functional adjacencies, such as locating the surgical intensive care unit adjacent to the operating suite. These adjacencies should be based on a detailed functional program which describes the hospital’s intended operations from the standpoint of patients, staff, and supplies.

Flexibility and Expandability

Since medical needs and modes of treatment will continue to change, hospitals should:

l               Follow modular concepts of space planning and layout

l               Use generic room sizes and plans as much as possible, rather than highly specific ones

l               Be served by modular, easily accessed, and easily modified mechanical and electrical systems

l               Where size and program allow, be designed on a modular system basis. This system also uses walk-through interstitial space between occupied floors for mechanical, electrical, and plumbing distribution. For large projects, this provides continuing adaptability to changing programs and needs.

l               Be open-ended, with well planned directions for future expansion; for instance positioning “soft spaces” such as administrative departments, adjacent to “hard spaces” such as clinical laboratories.

Therapeutic Environment Hospital patients are often fearful and confused and these feelings may impede recovery. Every effort should be made to make the hospital stay as unthreatening, comfortable, and stress-free as possible. The interior designer plays a major role in this effort to create a therapeutic environment. A hospital’s interior design should be based on a comprehensive understanding of the facility’s mission and its patient profile. The characteristics of the patient profile will determine the degree to which the interior design should address aging, loss of visual acuity, other physical and mental disabilities, and abusiveness. Some important aspects of creating a therapeutic interior are:

l               Using familiar and culturally relevant materials wherever consistent with sanitation and other functional needs

l               Using cheerful and varied colors and textures, keeping in mind that some colors are inappropriate and can interfere with provider assessments of patients’ pallor and skin tones, disorient older or impaired patients, or agitate patients and staff, particularly some psychiatric patients.

l               Admitting ample natural light wherever feasible and using color-corrected lighting in interior spaces which closely approximates natural daylight

l               Providing views of the outdoors from every patient bed, and elsewhere wherever possible; photo murals of nature scenes are helpful where outdoor views are not available

l               Designing a “way-finding” process into every project. Patients, visitors, and staff all need to know where they are, what their destination is, and how to get there and return. A patient’s sense of competence is encouraged by making spaces easy to find, identify, and use without asking for help. Building elements, color, texture, and pattern should all give cues, as well as artwork and signage.

Cleanliness and Sanitation

Hospitals must be easy to clean and maintain. This is facilitated by:

l               Appropriate, durable finishes for each functional space

l               Careful detailing of such features as doorframes, casework, and finish transitions to avoid dirt-catching and hard-to-clean crevices and joints

l               Adequate and appropriately located housekeeping spaces

l               Special materials, finishes, and details for spaces which are to be kept sterile, such as integral cove base. The new antimicrobial surfaces might be considered for appropriate locations.

Accessibility

All areas, both inside and out, should:

l               Comply with the minimum requirements of the Accessibility Standards.

l               In addition to meeting minimum requirements of  Accessibility Standards, be designed so as to be easy to use by the many patients with temporary or permanent handicaps

l               Ensuring grades are flat enough to allow easy movement and sidewalks and corridors are wide enough for two wheelchairs to pass easily

l               Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to dark and light; marking glass walls and doors to make their presence obvious

Controlled Circulation

A hospital is a complex system of interrelated functions requiring constant movement of people and goods. Much of this circulation should be controlled.

l               Outpatients visiting diagnostic and treatment areas should not travel through inpatient functional areas nor encounter severely ill inpatients

l               Typical outpatient routes should be simple and clearly defined

l               Visitors should have a simple and direct route to each patient nursing unit without penetrating other functional areas

l               Separate patients and visitors from industrial/logistical areas or floors

l               Outflow of trash, recyclables, and soiled materials should be separated from movement of food and clean supplies, and both should be separated from routes of patients and visitors

l               Transfer of cadavers to and from the morgue should be out of the sight of patients and visitors

l               Dedicated service elevators for deliveries, food and building maintenance services

Aesthetics

Aesthetics is closely related to creating a therapeutic environment (homelike, attractive). It is important in enhancing the hospital’s public image and is thus an important marketing tool. A better environment also contributes to better staff morale and patient care. Aesthetic considerations include:

l               Increased use of natural light, natural materials, and textures

l               Use of artwork

l               Attention to proportions, color, scale, and detail

l               Bright, open, generously-scaled public spaces

l               Homelike and intimate scale in patient rooms, day rooms, consultation rooms, and offices

l               Compatibility of exterior design with its physical surroundings

Security and Safety

In addition to the general safety concerns of all buildings, hospitals have several particular security concerns:

l               Protection of hospital property and assets, including drugs

l               Protection of patients, including incapacitated patients, and staff

l               Safe control of violent or unstable patients

l               Vulnerability to damage from terrorism because of proximity to high-vulnerability targets, or because they may be highly visible public buildings with an important role in the public health system.

Sustainability

Hospitals are large public buildings that have a significant impact on the environment and economy of the surrounding community. They are heavy users of energy and water and produce large amounts of waste. Because hospitals place such demands on community resources they are natural candidates for sustainable design.

Emerging Issues

Among the many new developments and trends influencing hospital design are:

l               The decreasing numbers of general practitioners along with the increased use of emergency facilities for primary care

l               The increasing introduction of highly sophisticated diagnostic and treatment technology

l               Requirements to remain operational during and after disasters

l               State laws requiring earthquake resistance, both in designing new buildings and retrofitting existing structures

l               Preventative care versus sickness care; designing hospitals as all-inclusive “wellness centers”

l               Use of hand-held computers and portable diagnostic equipment to allow more mobile, decentralized patient care, and a general shift to computerized patient information of all kinds. This might require computer alcoves and data ports in corridors outside patient bedrooms.

l               Need to balance increasing attention to building security with openness to patients and visitors

l               Emergence of palliative care as a specialty in many major medical centers

l               This might include providing mini-medical libraries and computer terminals so patients can research their conditions and treatments, and locating kitchens and dining areas on inpatient units so family members can prepare food for patients and families to eat together.

Hospitals are among the most regulated of all building types. Like other buildings, they must follow the local and/or state general building codes.