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Building Types by Robert F. Carr

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"A functional design can promote skill, economy, conveniences, and comforts; a non- Aesthetic Challenges
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functional design can impede activities of all types, detract from quality of care, and raise
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Community Services
Educational Facilities Air Barrier Systems in
Hospitals are the most complex of building types. Each hospital is comprised of a wide Buildings
Federal Courthouse range of services and functional units. These include diagnostic and treatment functions,
Air Decontamination
Health Care Facilities 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 VIEW ALL RELATED (43)
Hospital
function. This diversity is reflected in the breadth and specificity of regulations, codes, and
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Nursing Home oversight that govern hospital construction and operations. Each of the wide-ranging and
INDEX
constantly evolving functions of a hospital, including highly complicated mechanical,
Outpatient
electrical, and telecommunications systems, requires specialized knowledge and expertise.
WBDG SERVICES
Psychiatric 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
Land Port of Entry within the hospital can have competing needs and priorities. Idealized scenarios and
Libraries strongly-held individual preferences must be balanced against mandatory requirements,
actual functional needs (internal traffic and relationship to other departments), and the
Office Building financial status of the organization.
Parking Facilities
In addition to the wide range of services that must
Research Facilities
be accommodated, hospitals must serve and
Warehouse support many different users and stakeholders.
Ideally, the design process incorporates direct
Space Types input from the owner and from key hospital staff
early on in the process. The designer also has to
Design Disciplines be an advocate for the patients, visitors, support
staff, volunteers, and suppliers who do not
Design Objectives generally have direct input into the design. Good
hospital design integrates functional requirements
Products & Systems
with the human needs of its varied users.
VAMC Bay Pines, FL

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

its functions:

z bed-related inpatient functions

z outpatient-related functions
z diagnostic and treatment functions
z administrative functions
z service functions (food, supply)
z 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 logistic 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

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configuration is also influenced by site restraints and opportunities, climate, surrounding © 2008,
facilities, budget, and available technology. New alternatives are generated by new medical National
needs and new technology. Institute of
Building
Sciences.
In a large hospital, the form of the typical nursing unit, since it may be repeated many times,
All rights
is a principal element of the overall configuration. Nursing units today tend to be more
reserved.
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. (The trend, recently reinforced by HIPAA, is to all private
rooms.)

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:

z Promote staff efficiency by minimizing distance of necessary travel between

frequently used spaces
z Allow easy visual supervision of patients by limited staff
z Include all needed spaces, but no redundant ones. This requires careful pre-design
programming.
z 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
z 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
z Consolidate outpatient functions for more efficient operation—on first floor, if
possible—for direct access by outpatients
z Group or combine functional areas with similar system requirements
z 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:

z Follow modular concepts of space planning and

layout
z Use generic room sizes and plans as much as
possible, rather than highly specific ones
z Be served by modular, easily accessed, and easily
modified mechanical and electrical systems
z Where size and program allow, be designed on a
modular system basis, such as the VA Hospital
Building System. This system also uses walk-through
interstitial space between occupied floors for VAMC Albuquerque, NM
mechanical, electrical, and plumbing distribution. For
large projects, this provides continuing adaptability to
changing programs and needs, with no first-cost premium, if properly planned,
designed, and bid. The VA Hospital Building System also allows vertical expansion
without disruptions to floors below.
z 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

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and mental disabilities, and abusiveness. (See VA

Interior Design Manual.) Some important aspects of
creating a therapeutic interior are:

z Using familiar and culturally relevant materials

wherever consistent with sanitation and other
functional needs
z 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 (for in depth survey of research related
to Color in Healthcare Environments, see
CHER).
z Admitting ample natural light
wherever feasible and using
color-corrected lighting in
interior spaces which closely
approximates natural daylight
z 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 Cross-section showing interstitial space with deck above
available an occupied floor
z 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. (As an example, see VA Signage Design Guide.)

For an in-depth view see WBDG—Therapeutic Environments.

Cleanliness and Sanitation

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

z Appropriate, durable finishes for each functional space

z Careful detailing of such features as doorframes, casework, and finish transitions to
avoid dirt-catching and hard-to-clean crevices and joints
z Adequate and appropriately located housekeeping spaces
z 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:

z Comply with the minimum requirements of the Americans with Disability Act (ADA)
and, if federally funded or owned, the Uniform Federal Accessibility Standards
(UFAS)
z In addition to meeting minimum requirements of ADA and/or UFAS, be designed so
as to be easy to use by the many patients with temporary or permanent handicaps
z Ensuring grades are flat enough to allow easy movement and sidewalks and
corridors are wide enough for two wheelchairs to pass easily
z 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.

z Outpatients visiting diagnostic and treatment areas should not travel through inpatient
functional areas nor encounter severely ill inpatients
z Typical outpatient routes should be simple and clearly defined
z Visitors should have a simple and direct route to each patient nursing unit without
penetrating other functional areas
z Separate patients and visitors from industrial/logistical areas or floors
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z 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
z Transfer of cadavers to and from the morgue should be out of the sight of patients
and visitors
z 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:

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

z Use of artwork
z Attention to proportions, color, scale, and detail
z Bright, open, generously-scaled public spaces
z Homelike and intimate scale in patient rooms, day rooms, consultation rooms, and
offices
z 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:

z Protection of hospital property and assets, including drugs

z Protection of patients, including incapacitated patients, and staff
z Safe control of violent or unstable patients
z 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.

Section 1.9 of VA's HVAC Design Manual is a good example of hospital energy conservation
standards that meet DOE requirements. Also see LEED's (Leadership in Energy and
Environmental Design) Green Building Rating System for sustainability standards for
construction projects.

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

z The decreasing numbers of general practitioners along with the increased use of
emergency facilities for primary care
z The increasing introduction of highly sophisticated diagnostic and treatment
technology
z Requirements to remain operational during and after disasters—see, for example,
VA's Design and Construction Procedure: Natural Disaster Non-Structural Resistive
Design
z State laws requiring earthquake resistance, both in designing new buildings and
retrofitting existing structures
z New HIPAA (Health Insurance Portability and Accountability Act) regulations address
security and privacy of "protected health information" (PHI). These regulations put
new emphasis on acoustic and visual privacy and may affect location and layout of
workstations that handle medical records and other patient information, both paper
and electronic, as well as patient accommodations.
z Preventative care versus sickness care; designing hospitals as all-inclusive "wellness
centers"
z 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.
z Need to balance increasing attention to building security with openness to patients
and visitors

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

z A growing interest in more holistic, patient-centered treatment and environments such
as promoted by Planetree. 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.

Relevant Codes and Standards

Hospitals are among the most regulated of all building types. Like other buildings, they must
follow the local and/or state general building codes. However, federal facilities on federal
property generally need not comply with state and local codes, but follow federal regulations.
To be licensed by the state, design must comply with the individual state licensing
regulations. Many states adopt the AIA Guidelines for Design and Construction of Hospitals
and Health Care Facilities, listed below as a resource, and thus that volume often has
regulatory status.

State and local codes, which in the past have frequently been based on the three regional
model codes, are now often being based on the model International Building Code (IBC).

Since hospitals treat patients who are reimbursed under Medicare, they must also meet
federal standards, and to be accredited, they must meet standards of the Joint Commission
on the Accreditation of Healthcare Organizations (JCAHO). Generally, the federal
government and JCAHO refer to the National Fire Protection Association (NFPA) model fire
codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code
(NFPA 101).

The Americans with Disabilities Act (ADA) applies to all public facilities and greatly affects
the design of hospitals with its general and specific accessibility requirements. The Uniform
Federal Accessibility Standards (UFAS) apply to federal and federally-funded facilities. They
are not greatly different from ADA requirements.

Regulations of the Occupational Safety and Health Administration (OSHA) also affect the
design of hospitals, particularly in laboratory areas.

Federal agencies that build and operate hospitals have developed detailed standards for the
programming, design, and construction of their facilities. Many of these standards are
applicable to the design of non-governmental facilities as well. Among them are:

z Department of Veterans Affairs (VA), Office of Facilities Management Technical

Information Library contains many guides and standards, including:
{ Design Guides for planning many different departments and clinics, design
manuals of technical requirements, equipment lists, master specifications,
room finishes, space planning criteria, and standard details.

Major Resources

Websites

z American Hospital Association—Information generally focused on financial and

organizational issues, but includes good information on health care statistics and other
resources.
z American Society of Interior Designers and The University of Minnesota—The first
centralized clearinghouse for design and human behavior research on the Web.
z Green Guide for Health Care™—A best practices guide for healthy and sustainable
building design, construction, and operations for the healthcare industry.
z Hospitals for a Healthy Environment—A four-member partnership between the
Environmental Protection Agency, American Hospital Association, American Nurses
Association, and Healthcare without Harm to educate healthcare professionals about
pollution prevention.
z Society for the Arts in Healthcare (SAH)—National and international advocacy group for
the integration of the arts into the healing healthcare environment.
z U.S. Green Building Council

Publications

z Building Type Basics for Healthcare Facilities , ed. Stephen Kliment. New York: John
Wiley & Sons, Inc., 2000.
z Design Details for Health: Making the Most of Interior Design's Healing Potential by
Cynthia A. Leibrock. New York: John Wiley & Sons, Inc., 1999.—Innovative design
solutions in key areas such as lighting, acoustics, color, and finishes
z Design Guide for Improving Hospital Safety in Earthquakes, Floods, and High Winds:
Providing Protection to People and Buildings. FEMA, 2007.
z Design That Cares: Planning Health Facilities for Patients and Visitors, 2nd Edition , by

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Janet Carpman, Myron Grant, and Deborah Simmons. New York: John Wiley & Sons,
Inc., 2001.
z Development Study—VA Hospital Building System by Building Systems Development
and Stone, Marraccini & Patterson. Washington, DC: U.S. Government Printing Office,
rev. 1977.
z Emergency Department Design: A Practical Guide to Planning for the Future by John
Huddy and Michael T. Rapp. Irving, Texas: ACEP (American College of Emergency
Physicians) 2000.
z Guidelines for Design and Construction of Hospitals and Health Care Facilities by AIA
Academy of Architecture for Health. Washington, DC: The American Institute of
Architects, 2001.
z Healthcare Design , ed. Sarah O. Marberry. New York: John Wiley & Sons, Inc., 1997.
z Health Facilities Management—A monthly journal of the American Hospital
Association's Health Forum. It serves the health facility operations, maintenance,
construction, and environmental services community.
z Healthcare Facility Plannning-Thinking Strategically by Cynthia Hayward, AIA, FAAHC,
ACHA. Health Admnistration Press and the American College of Healthcare Executives,
2005.
z Health Facilities Review 1992-1993 and subsequent by AIA Committee on Architecture
for Health. Washington, DC: AIA Press.
z Hospitals and Health Networks—A monthly journal of the American Hospital Association
covering general health care news, with occasional articles on design and construction
z Hospitals, The Planning and Design Process, 2nd ed. by Owen B. Hardy and Lawrence
P. Lammers. Rockville, Md.: Aspen Publishers, 1996.
z Hospital Interior Architecture: Creating Healing Environments for Special Patient
Populations by Jain Malkin. New York: John Wiley & Sons, Inc., 1992.
z Healthcare Design—A quarterly magazine with design articles and presentations of
recent projects
z Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment,
and Clinical Procedures, 3rd Edition , by Jain Malkin. New York: John Wiley & Sons,
Inc., 2002.
z Modern Healthcare—A weekly journal for healthcare executives with frequent articles
on design and construction and an annual design awards program. Online archives of
articles back to 1994.
z Time Saver Standards for Building Types, 2nd ed. by Joseph De Chiara and John
Callender. New York: McGraw-Hill, 1980.

Tools

z SpaceMedGuide-A Space Planning Guide for Healthcare Facilities—a popular planning

tool providing state-of-the-art planning methodologies, industry benchmarks, and
planning tips.