By Garry Coff
Health Facility Planner at Garry Coff Consulting Services– Sustainability in Health Design. As an architect, Garry Coff has been involved with health design for decades. During this podcast, Garry sits down with AHDC to discuss the importance of sustainable health design what the future of ‘green’ buildings will look like. From Adelaide, Garry has worked across the globe and has been able to evolve his designs based on current economic, political and climate requirements.
Born and educated in Broken Hill, I moved to Sydney to study and qualify as an Architectural Technician at almost exactly the time of the Mainline Constructions collapse. This collapse left the city with many new, empty multi-storey buildings to be tenanted by a large number of American business organisations seeking to set up in Australia (including Honeywell, IBM & General Electric, etc.).
I learned about workflow planning with these projects before moving to South Australia in 1980. Here I broke into the Health Design market as a Project Officer on a major health redevelopment Project in Adelaide. This project was designed by Woods Bagot in collaboration with Lawrence Neild & Partners.
I moved on from that project and joined the SA Health Commission, where I was exposed to many rural hospitals that had mostly been built in the mid 50’s to early 60’s. These that were based on UK concepts, all expecting to grow to 400-bed facilities – but never reached more than between 50 to 200-beds. They were generally providing community support to populations that worked hard, lived hard and needed to be propped up to get clear of the booze – patients were given nutritious food and safe sleeping accommodation for a couple of weeks to regain their health so that could get back to work.
These facilities were pretty extravagant and demonstrates the optimism of the community’s expectation for growth of population and industry – they had Kitchens designed to feed a warship with big boiler systems and massive air conditioning plant, and Laundries large enough to support the whole Regional populations.
During the 1980’s sustainability started to become a design issue, but it really kicked off in the 2000’s when ‘design for purpose’ started and included steps to curb these extravagancies and address operating costs.
Hospitals invariably require a lot of external wall and many windows, so major gains can be realised from simple orientation and shading – a little less concern about the view and some focus on the cost of operation will benefit the quality of the accommodation and reduce energy consumption. There is so much to be gained from basic principles and even more that can be gained from simplifying engineering components. Australians love a challenge, and we went through a lot of projects where we felt the need to compete with nature to achieve an acceptable outcome. We were encouraged to believe that you can build an igloo in the middle of a desert – Dubai is an excellent example of this – enough money and it is all possible. There are a lot of examples around now that demonstrate attitudes are changing.
I have a client that wants to build a Passive Health building. He has secured an ideal site in the middle of an ‘Innovation Development Precinct’ in Adelaide – this building is 4-storey Medical Centre that will effectively run on the smell of a ‘disinfection cloth’. It comprises a 4-OR Surgical Procedure Suite, a floor of General Practice Consulting (Melanoma Diagnosis) and dermatology and cancer treatments, Specialist Consulting Suites, Day Hospital and on-site Medical Imaging (MRI, CT Scanning, Ultrasound and Fluoroscopy), Pathology, Dentist and Pharmacy.
The building is designed as a completely sealed building with controlled air management that will be clad with Solar panels and water distribution through the structure to maintain a set temperature of, say, 22 degrees Celsius 24/7.
By Professor Ross Donaldson
Professor Donaldson’s background as an Architect has led him to become a global sensation in the world of Health Design and sustainability. From Asia to USA, UK and Australia Ross has lectured around the world on the importance of climate change and how design can help reduce our carbon footprint. Currently the Chairperson of Bridge 42, Ross is also on the Board of the Australian Health Sustainability Council, National taskforce on Australian institute of architects taskforce on climate change, and is Adjunct Professor at Uni WA, whilst also working as a lecturer at Curtain University on in the world of sustainability.
A critical part of that science is contained in the IPCC’s Sixth Assessment Report, released earlier this year titled “Code Red for Humanity”. Its critical message is that our focus must be on 2030 and the imperative for decarbonising the economy by 50%, as a minimum.
It is generally agreed that cities and construction account for 39% of the challenge. As practitioners within the construction industry, our responsibility for 2030 is thus nearly 40% of the problem and we must embrace the challenge.
Generally, we are not even measuring how much carbon there is in the buildings we are designing. If we are not measuring, how can we accurately understand how to reduce the amount of carbon by 50% within the critical timeframe? We need to be measuring the “whole of life carbon” in our buildings.
Whole of life carbon is determined through a “Life Cycle Assessment” (LCA) measuring:
The phases in the life of a building are captured in the European Standard for measuring carbon in buildings, EN15978.
Figure 1: European Standard for Measuring Carbon in Buildings EN15978
If we need to reduce whole of life carbon by 50% by 2030, and currently most buildings are produced without any measurement of their carbon, we will need to accelerate our understanding of how this is to be done. We must build the capacity and capability of clients, authorities and consultants to understand and deliver carbon measurements. It will be very difficult to move to 50% reduction without a period of measurement and reporting.
If we are to get the whole construction industry decarbonising at this rate, we can’t expect this to happen without the regulatory environment to be mandating a 50% reduction as a performance benchmark. We will therefore need the next review of the NCC in 2025 to at least mandate reporting of whole of life carbon, with performance benchmarks for 2030 being introduced in the 2028 review at the latest.
This pathway is already well developed in the UK where they are advanced in the introduction of Part Z to the UK Building Regulations, their equivalent of our NCC. They are seeking to start the introduction of reporting in 2023 and gradually elevate the carbon performance benchmarks from there. The House of Commons Environmental Audit Committee’s Report in May 2022 opens with “…the single most significant policy the Government could introduce is a mandatory requirement to undertake whole-life carbon assessments for buildings.”
On this subject the UK is showing us the way. We now need leadership from clients, approvals authorities and consultants in the measurement of whole of life carbon. If we are not prepared to sign up to this challenge, we are, by implication, “climate deniers”.
One of the challenges we have is that there has developed a form of complacency that sits around a comfort, that if we are doing something, we are doing enough. But it isn’t.
What must we do?
And learning quickly how to design the carbon out – operational and embodied.
By Florence Wong
Florence is a PhD candidate at the University of NSW in Australia. Florence has a background in Architect from HK University and has grown her career in the world of sustainable architecture. Florence discusses her research into mass timber construction and investigating its feasibility in hot and humid South East Asian Cities.
To meet the goal of the Paris Agreement to limit the global temperature increase below 1.5oC, the global economy is aiming to achieve net zero carbon emission by 2050. We know that the building sector contributes a major part of carbon emissions of up to 37% in 2020. So, the building industry worldwide is seeking ways to lower this as it develops the built environment.
In the past 20 years, a major development of mass engineered timber (MET) products has seen the lamination of smaller timber pieces into larger structural components, e.g., cross-laminated timber (CLT). Modern methods of construction have also been progressed, including digitalization in design and prefabrication. DfMA (Design for Manufacturing and Assembly is a way to increase efficiency and improve the quality of building construction by shifting most of the process into factories.
As a result, MET construction using prefabricated timber components is increasingly used to achieve sustainable building construction. Timber is a renewable material and can sequester carbon as trees grow. The carbon is subsequently sequestered in the built structure. Using timber in construction, plus possibly working together with other building materials as hybrid structures, could provide a solution for sustainable and efficient construction of larger scale contemporary buildings.
Multi-storey MET and hybrid buildings are being built in many overseas countries. These are frequently facilitated by new government policies and updated building codes. However, most of these buildings are concentrated in Europe, UK, and North America. More are now being built in Australia but only a very few in Asia. This research aims at finding out the reasons for this slow adoption, particularly in the hot and humid SE Asian cities of Singapore and Hong Kong. Our research will systematically investigate and analyse the parameters of these cities and the barriers that are affecting the adoption of multi-storey MET and hybrid buildings.
We will also compare these cities to Brisbane, Australia which has a similar climate yet is moving quickly in adopting timber construction. There are already many multi-storey MET projects completed in Australia, and proposals lodged that include hybrid high-rises up to 40 storeys in Sydney.
Some people may question whether increasing the supply of timber will risk deforestation of our native landscapes. Other people may also remember previous issues with timber construction such as its perceived lack of durability and risks of fire often derived from depictions of historic catastrophic blazes. However, in recent decades, advanced technologies, full-scale fire testing and certification of timber supply, have provided feasible solutions to address these constraints.
A further aim of this research is sharing the knowledge of these advances and the experience gained from completed projects with the building industry. This industry is beginning a steep learning curve regarding MET construction. In time, we believe that more successful MET projects will be completed and ultimately appreciated by the public.
By Anahita Sal Moslehian, PhD, EDAC
Anna is a professional researcher working on healthcare building design. For more than five years, she has been examining the impacts of hospital building design on occupants’ health and wellbeing to create facilities that promote healthier environments for patients and staff. Anna’s expertise expands to design innovation, biophilic design and restorative environment design. During her PhD study, Anna developed her systematic thinking and interdisciplinary research skills that are crucial for generating knowledge in the highly multi-disciplinary context of healthcare design leading to timely design innovations. She is currently a Postdoctoral Research Fellow with HOME Research Hub and Live+Smart Research Lab in the School of Architecture and Built Environment at Deakin University.
LinkedIn: www.linkedin.com/in/anahitamoslehian | ORCID 0000-0002-5692-6748
Correlational evidence suggests that place can significantly impact a person’s health, well-being, emotions, self-esteem, security and identity. The impact of the built environment on health and well-being is particularly important when considering the design of healthcare facilities. This is especially true for the most complex form of healthcare building – the hospital.
Medical practitioners, architects, and environmental psychologists have long acknowledged the link between hospital buildings and outcomes such as the potential mitigation of ill health, improved workplace performance, lower staff turnover, and greater organisational efficiencies. Hospital building design innovation may play a critical role in enhancing the quality of care, promoting the healing process, and overcoming past errors and inefficiencies.
Despite the steady increase of research in this field, it seems that few innovations are generated from this research and the process of change is too slow. Hospital building designers and policymakers often face obstacles in fully integrating research evidence into design practice; a phenomenon known as the Research-Practice (R-P) gap. The literature highlights the R-P gap as the biggest challenge of all hindering innovation in hospital design, leading to repeated, similar shortcomings. Six main groups of causes are discussed for the R-P gap in the context of healthcare design with the aim of narrowing this gap and increasing the chance of design innovation (please refer to Sal Moslehian et al., (2020) for a detailed explanation of the reasons behind the R-P gap).
My PhD study, however, argues that an oversimplification of the wider context of the evidence base for the design of hospital buildings, including focusing on one object for innovation at a time, has been a prime obstacle to design innovation. Tracking the evolution of hospital building design through time reveals that hospital design has shifted and developed not just according to research, but also in relation to the strength of many other factors, for example, social shifts, political decisions and policies, war, and architectural design trends as well as medical and technological advancements (see Figure 1). Indeed, innovation in hospital building design is a complex ecosystem with various dimensions and the R-P gap is only a small part of a more complex picture. Overlooking this complexity and therefore insufficient understanding of the nature of innovation in hospital building design has been one of the critical factors in the shortage of timely design innovations in this field.
Figure 1: Schema illustrating the impacts of various factors on innovative moments in hospital design (Sal Moslehian et al., 2020)
The key aim of my study is to conceptualise the evolution of hospital building design over the past 100 years, as well as identify and explain the main factors triggering design innovation. I adopted systems thinking to understand the complex set of interdependent variables associated with hospital designs. My research highlights the main components of the innovation ecosystem, the most influential contextual factors, the most interrelated factors, and the overall behaviour of the innovation ecosystem in this field.
Figure 2: The explanatory innovation framework in hospital building design (Sal Moslehian et al., 2022)
As can be seen in Figure 2, my research represents an explanatory innovation framework, containing 617 interconnections between 146 factors classified across 14 categories: Architectural Movements, Urban Reforms, Research Developments, Advances in Medical Science, Technological Developments, Shifts in Attitudes Towards Health, Transition in Institutional Identity, Healthcare Policy, Political Shifts, Economic Shifts, Social Transformations, Developments in Health Service, Shifts in Organisational Culture, and Shifts in Natural Environment. My study argues that the complex innovation ecosystem involves several dynamic actors and multi-faceted processes with both individual and collective impacts on design innovations in hospital building design.
The infrastructure of the innovation ecosystem suggests that design innovations generally arise in many different ways and are often subject to heterogeneous factors that are often neither linked nor mutually exclusive. My study helps researchers, hospital designers, healthcare developers, policymakers, and stakeholders adopt a multidimensional outlook to further develop the system by representing and mapping the successful processes and prior interactions between less-examined contextual factors in this field. This knowledge also allows for the identification of critical interventions and potential collaborations between key players on multiple fronts in generating innovation processes.
Lack of intent has never been the main reason behind any shortcomings in hospital building design. However, the lack of a holistic approach and thus an accurate understanding of the interplay between involved factors, as well as the inability to see how different forces align to add value to the system, have contributed to a lack of understanding of the dynamics of change.
Given the critical role of the healthcare industry, better knowledge of the nature of innovation in hospital building design can not only enhance healing processes and increase organisational efficiency. Such knowledge can also inform stakeholders in other construction industries leading to further innovation and value creation.
Considering the increasingly growing demand for health for all, design innovation in different building types will bring unprecedented opportunities to the health and well-being of humans/society and the environment/ecology.
Sal Moslehian, A., Kocaturk, T., & Tucker, R. (2021). An integral view of innovation in hospital building design: understanding the context of the research/practice gap. Building Research & Information, 1-16.
Sal Moslehian, A., Tucker, R., & Kocaturk, T., Andrews, F. (2022) The Nature of Innovation in Hospital Building Design: A Mixed Grounded Theory Study. Construction Innovation. Ahead-of-print.
Sal Moslehian, A., Tucker, R., Kocaturk, T., & Andrews, F. (2022) An Analysis of Design Innovation in Hospital Building Design over the Past 100 Years. HERD, Health Environments Research & Design.
By Katharina Nieberler-Walker
PhD Scholar, Griffith University, Director, Australian Institute of Landscape Architects (AILA)
Building on a career in landscape architecture, which included the design and establishment of the 11 healing gardens at the Queensland Children’s Hospital, Katharina’s research consolidates her practical expertise by creating a framework to optimise the health-promoting qualities of therapeutic hospital gardens. This will assist patient recovery, support family well-being and improve staff performance and satisfaction.
Gardens are a valuable tool for improving health and well-being in the hospital environment and may benefit many people. Health and nature are intrinsically linked and the positive impacts of nature become available when gardens are included in healthcare settings.
Those who build or work in clinical environments, such as hospitals, understandably prioritise infection control. The resulting tightly controlled care settings are inevitably air-conditioned, with inoperable windows, bright lights and smooth, often white and shiny surfaces for easy cleaning. These clinical settings, however, feel and smell unfamiliar and this strangeness is heightened when a patient is vulnerable or ill, or as a carer, concerned for a loved one.
Eastern Gardens and Plaza, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
Traditional clinical environments can create stress, anxiety, and on occasion, irrational thinking by patients and their families. An explanation for this increased stress may be that human evolution closely parallels that of the natural world. As a result, the amygdala, the ancient part of our brains, may be unable to read the clinical environment quickly and effortlessly in guiding our “flight” or “fight” response. This appears comparable to a malfunctioning computer that gets stuck in a loop because of a missing or incorrect piece of code. The computer cannot process incoming information, and this causes the machine to malfunction.
Green Roof, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
Hospital gardens are increasingly provided because of their health-promoting qualities. However, the anticipated user experience is rarely achieved, generally because health-promoting hospital gardens are ill-defined, variable in terms of quality and so their impact is also difficult to assess. Negative or unquantifiable outcomes can waste money, time and goodwill, and undermine the value of hospital gardens.
View to the CIty, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
We need to establish how therapeutic hospital gardens should look and how they may be experienced by patients with varying health conditions and other users including staff. We need to understand how to design these gardens and in doing so, also produce credible, replicable and useful research.
My research investigates the creation of a design framework for therapeutic hospital gardens (THGs). This framework will enable healthcare professionals, policy setters, decision-makers, designers and hospital administrators to purposefully design and integrate THGs successfully into every hospital to benefit many different users.
Secret Garden, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
Transdisciplinary research is required due to the complexity of THG design and design processes. Knowledge must be derived from more than “argument and logic”, it must also be drawn from the “art of design” that is, outside the logic paradigm. “Landscape design” which includes technical knowledge and logic is a skill that takes years to master and is hard to perfect.
“Argument and logic” is one source of knowledge, and “skill and practice” is another equally valid foundation for knowledge creation. Being across both camps enables better insight into the complexity of THG design. Both types of knowledge support the creation of purposefully designed and well-integrated THGs, and thence, the optimisation of the health-promoting benefits of THGs. This process of integration is critical to the success of the end product and makes teamwork essential.
Pathways in the Secret Garden, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
My scholarly systematic literature review (SLR) examined 28 peer-reviewed academic articles published in the last five years that analysed the reported benefits and values of THGs. The SLR focused on three key terms – “hospital gardens”, “health” and “therapeutic” – establishing a clear scope for a thorough investigation of the topic of THG. While the SLR is one small step towards establishing THGs globally, it is important in that it defines the benefits/ values of THGs and the knowledge base for the rest of the study. The SLR is a substantial resource that demonstrates the status and progress towards creating THGs at this time. It is noteworthy that, over the last 10 years, there has been an exponential increase in the number of scholarly publications that highlight the intrinsic and tangible benefits of linking nature with health in clinical environments .
Conducting the SLR established a baseline in terms of both practice and research related to THGs. It confirmed that this research can make a useful contribution by creating a framework that informs the design and creation of THGs. The SLR is substantially complete and I look forward to sharing the results and findings from this SLR when it is published later this year.
Seating Spaces in the Secret Garden, Queensland Children’s hospital, Conrad Gargett, Photo Christopher Frederick Jones
I will commence my primary research by asking practitioners and experts in the field of healthcare design, human and environmental health, and healthcare governance about their experiences in establishing THGs. My aim in conducting this primary research is to gather empirical evidence regarding how THGs are currently established in practice and how this evidence can inform the THG framework.
My research is based in the real world. My research will enable practitioners, designers and hospital administrators to create purposefully designed and well-integrated hospital gardens globally, to further human, environmental and organisational health. Ultimately, this will serve the common good.
To learn more about this subject, please contact me.
I acknowledge the traditional owners of the lands on which I work. I pay my respects to Elders past and present.
By Alison Huynh
Alison Huynh is a Sydney-based architect specialising in design for healthcare, mental health, master planning and urban design strategy for hospitals.
Working in healthcare environments is clearly understood to be stressful and demanding. Long working hours, shift-based work, high-intensity work, and exposure to pain, suffering and death can take their toll on psychological wellbeing. Burnout and poor wellbeing in healthcare workers are undoubtedly associated with poorer patient safety[i]. This is a correlation that has a significant implication for designers in healthcare settings. It indicates that by supporting staff wellbeing, we can support safer patient care.
As designers, we often highlight the importance of positive spatial experiences for patients, and the need to create environments that reduce stress and improve patient satisfaction. Meanwhile, staff spaces are often designed for efficiency, travel distances, infection control and logistics. Clearly, we need to go beyond physical safety in occupational environments to support holistic staff wellbeing.
We know that doctors and medical students have substantially higher rates of psychological distress and suicidal thoughts when compared with both the Australian population and other professionals. This disproportionately affects young doctors, female doctors and students, and indigenous students[ii].
Additionally, a cross-sectional survey conducted during Australia’s first COVID-19 pandemic phase in April-May 2020 indicated that healthcare workers showed significant symptoms of moderate-severe level depression (21%), anxiety (20%) and posttraumatic stress disorder (PTSD; 29%)[iii]. This is despite low levels of COVID-19 contact in Australia. This is consistent with early international reports that the pandemic had a considerable impact on the psychological wellbeing of front-line hospital employees around the world[iv].
The workplace of many healthcare employees is highly varied and complex. It incorporates both the physical environment as well as virtual environments. For nursing staff and carers, there is a significant amount of multi-tasking and movement between spaces, from the bedside to the staff station. For other staff, such as consultants and allied health professionals, their experiences may be characterised by hybrid work, working remotely and utilising video conferencing to assess patients, share information and provide support.
Multi-modal working environments in the Hospital lead to significant amounts of multi-tasking and distracted work processes. Royal Children’s Hospital Melbourne by Bates Smart, Billard Leece and HKS. Photography © Shannon McGrath
During the COVID-19 pandemic, the pressure to effectively manage infection control through personal protective equipment and other risk management procedures added extra stress and fear of infection to the burden of care[v]. Another common challenge of the pandemic was the need for staff to quickly be redeployed into new environments. They may have put aside non-essential activities to meet urgent needs, compromising the holistic and therapeutic quality of care they would normally provide. This can lead to psychological distress and reduced job satisfaction, leading to a desire to leave the profession.
Welcoming and uplifting design in the Hospital can ameliorate the environment and support wellbeing for staff, patients and visitors. Bendigo Hospital by Bates Smart and Silver Thomas Hanley. Photography © Shannon McGrath
Regular breaks are essential to high-intensity work, especially when coupled with long hours and shift-based work. Improved design of respite spaces can support a range of activities relating to staff wellbeing. Respite spaces allow for a moment to take a breath without leaving the unit. These spaces facilitate peer support, providing a place for private conversations and debriefing during periods of high stress. By prioritising staff privacy, these spaces also encourage practical training by providing a safe environment for students to ask questions.
These spaces need to be more than tea and coffee stations. Ideally, staff respites need to be well-integrated and fairly distributed to encourage active use. A variety of spaces should be considered, from cheerful and daylit spaces with distance views and connection of nature to lift the mood and rest the eyes. Soft and darkened spaces can provide a sense of retreat and relief from the bright lighting and constant noises on the unit. They may accommodate two-four people, and they may be visually connected with other spaces. However, acoustic privacy and reduced distraction are of paramount importance.
Shared staff spaces that have good access to natural light and distance views can incorporate a range of seating options, including small group settings, or space to be alone. Rooftop terraces can provide private spaces close to acute services and other amenities. Workshop by Bates Smart. Photography © Brett Boardman.
The hospital is a learning environment for all staff and in all areas. Flexible and engaging training spaces that are embedded in the healthcare environment encourage attendance and support trainees on the job. Medical students and other trainees should have opportunities to talk to lecturers and connect with other students in formal and informal settings.
In a rapidly changing world, staff at every stage in their career need high-quality training and continuing education to develop their skills, advance their career and maintain up-to-date knowledge. Often in a busy work environment, it can be hard to carve out the time to dedicate to education. Staff often need to remain available on-call and have expressed concern that essential training and education might be reducing their time for caregiving duties.
In a fast-developing educational environment that is becoming increasingly reliant on remote training, it is important that hospital and university spaces are closely linked. This is supported by equitable and accessible room booking systems and the optimised use of multi-purpose spaces thus reducing departmental footprints and increasing flexibility.
In many cases, the spaces that healthcare workers need to rest, recover and learn are embedded in the floor plan, deprioritised as time goes on and sometimes lost in the planning process. Even a robust stakeholder engagement process can struggle to balance clinical, infrastructure and environmental priorities.
As designers we need to clearly identify these staff spaces as a part of a vital network within the hospital, ensuring equality of access and quality of spatial design. Often associated with the flexible fit-out zones of the hospital, staff spaces may occupy zones earmarked for future expansion, and therefore a strategy must be in place to ensure that they are adequately re-provided and continually refreshed.
Even when there are no windows or natural light available nearby, soft furnishings and lighting provide a restful retreat. Space for 1-2 people provides opportunities for individual respite or a quiet conversation. This can be located within staff zones or circulation spaces. Iglu Franklin St by Bates Smart. Photography © Peter Clarke
[i] De Kock, J.H., Latham, H.A., Leslie, S.J. et al. A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health 21, 104 (2021). https://doi.org/10.1186/s12889-020-10070-3
[ii] Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB (2016) Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLOS ONE 11(7): e0159015. https://doi.org/10.1371/journal.pone.0159015
[iii] beyondblue Doctors’ Mental Health Program. National Mental Health Survey of Doctors and Medical Students, 2019, https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmss-full-report_web
[iv] Dobson H, Malpas CB, Burrell AJ, et al. Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic. Australasian Psychiatry. 2021;29(1):26-30. doi:10.1177/1039856220965045 https://journals.sagepub.com/doi/full/10.1177/1039856220965045#bibr3-1039856220965045
[v] De Kock, J.H., Latham, H.A., Leslie, S.J. et al. A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health 21, 104 (2021). https://doi.org/10.1186/s12889-020-10070-3
By Dr Jane Repin Carthey
COVID-19 has shaken up the world of healthcare design
COVID-19 has shaken up the world over the last 18 months or so. Travel, socialising, employment and business have taken a massive hit, and the health sector has possibly undergone the biggest evolution. Health services, including hospitals (ED, ICU and IPU) and front line service providers such as GPs, have had to consider how they do business. Their concerns have included reducing the spread of infection, keeping non-infectious staff and patients safe, and providing adequate, suitable capacity to respond to increased demand for treatment and hospital beds. We are now moving into the next phase of the pandemic, where safely vaccinating people, as quickly as possible, is the primary concern.
The hospitals and other buildings that support healthcare delivery are rarely the priority in this type of situation. The organisational models for care delivery plus the associated workforce are the first consideration in such circumstances. However, these models and their staffing requirements must have suitable physical facilities to deliver the necessary health services. This short piece summarises a review of international and national responses to the demands of the pandemic on healthcare facilities. It is not intended to be comprehensive and will be expanded in future blog posts.
This list was developed for the Optimising Health Environments Seminar 2021 as an overview of the types of literature available relevant to the future design of healthcare facilities to cope with pandemics.
Although the output of peer-reviewed literature dealing with the Covid-19 is increasing, most of it is to date is related to clinical and organisational issues rather than facility responses. Some academics are writing about facility issues, with output expected to increase in quality and quantity over the next year. Trade and similar publications contain articles regarding possible facility responses. Architects’ professional associations publish guides and articles in some countries. Globally, the Union of International Architects Public Health Group (UIAPHG) has dedicated a website page to a list of these resources. Some of the larger consulting firms have published guides to designing healthcare facilities to cope with Covid-19, and most of these also suggest how to futureproof facilities against the next pandemic.
Healthcare Design Magazine
(USA) Albert, J. (2020). Reimagining Healthcare Design After COVID-19 [Perspective / opinion]. Healthcare design. Retrieved August 9, 2020, from https://www.healthcaredesignmagazine.com/trends/perspectives/reimaging-healthcare-design-after-covid-19/
Fowler, J. (2020). Strategies for Reopening During The COVID-19 Pandemic [Opinion]. Healthcare design. Retrieved August 9, 2020, from https://www.healthcaredesignmagazine.com/trends/perspectives/strategies-for-reopening-during-the-covid-19-pandemic/
McCarthy, A. (2020). Implications of COVID-19 on Healthcare Design. Healthcare design. Retrieved August 14, 2020, from https://www.healthcaredesignmagazine.com/trends/perspectives/implications-of-covid-19-on-healthcare-design
Kacik, A. (2020). Pandemic prompts flexible healthcare design. Modern Healthcare, 50(20), 2
Stone, K. (2020). Planning Next: The eReport for planning and designing health’s future beyond COVID-19. https://www.cannondesign.com/ereport/
Ramboll. (2021). Pandemic Resilience. Retrieved February 15 from http://www.pandemic-resilience.com/
Eastwood, T. (2020). Pandemic preparedness: How hospitals can adapt buildings to address worst-case scenarios. Stantec. Retrieved April 13 from https://www.stantec.com/en/ideas/content/blog/2020/pandemic-preparedness-how-hospitals-can-adapt-buildings-to-address-worst-case-scenarios
Following is a summary of some of the key findings and issues to be considered from the literature to date. These findings are sorted under several headings – although some may be relevant to more than one of these themes. The work of Arup/HKS is acknowledged with many illustrations drawn from their excellent document – referenced above.
There will be another pandemic! We need to be better prepared.
The New Yorker (Emma Roulette)
By Dr Harm Hollander
Harm Hollander is a Principal with Conrad Gargett and has a desire to advance improvements in the health care environment. A Fellow of the Australian Institute of Architects, Harm has also lectured in Construction, Professional Studies and Design at various universities. He has developed comprehensive skills in leading large projects from commencement to completion, working meticulously through brief, design and delivery challenges. As a recent graduate with a Doctorate of Creative Industries, Harm remains the student in seeking further improvement towards better design outcomes.
The flexibility of a hospital is not always about the alteration of the physical environment. However, there are three main approaches (or streams) most often used to support physical change :
A. multi-use (where the building fabric is modelled to suit a variety of uses).
B. fit-out flexibility (the ability to easily change the building fabric), and
C. fitments (user instigated changes to fittings and fixtures).
A. multi-use (where the building fabric is modelled to suit a variety of uses).
B. fit-out flexibility (the ability to easily change the building fabric), and
C. fitments (user instigated changes to fittings and fixtures).
This article is the second in a series discussing flexibility inside hospitals. The first article expanded on stream ‘A’ – multi-use, including premanufacture and modularisation of key building components. That article suggested specific synthesised solutions, including consistent presentation, universal rooms, and modular planning.
Before exploring the second major stream of flexibility, fit-out flexibility, it is necessary to consider whether the many potential fabric change solutions are viable or cost-effective. Potential flexibility strategies driven by the fit-out construction method may vary from the utopian objective of columnless floor areas and dedicated interstitial plant floors to the other end of the spectrum – the simplification of construction. The main difference between these extreme ends of the flexibility spectrum is viability.
Flexibility initiatives are less likely to be executed if they present an initial cost penalty, are difficult to instigate, overly disruptive, take a long timeframe to deliver, are based on unrealistic forecasts, or if the intent is misunderstood. A columnless floor layout is likely to be high in cost relative to the potential benefits. Simplified construction is more likely to be a good value proposition and more change-adaptable. Typically, viable design responses often involve deliberate, simple forms of construction or combine benefits for neutral (or near-neutral) capital costs.
Some examples of simplified flexibility initiatives include:
Figure 1: A model demonstrating the “planes” in simple terms; the floor, the suspended ceiling including the reticulated services in the interstitial ceiling space and the next floor over; these form the “planes”. There can be a simple to complex arrangement in filling between these components, depending on how design further approaches the issues.
Figure 2: A flush, self-draining floor system without requiring a concrete floor rebate.
These six examples all require re-thinking the over-arching objectives of the design. The strategies consider future flexibility needs yet involve negligible (or even negative) cost penalties. They are examples of a greater number of simplified flexibility initiatives that could be further investigated by the wider profession as part of examining ongoing opportunities for enabling viable change inside hospitals.
There are currently hopeful signs of an overall and growing interest in enhancing levels of simplification to create greater flexibility in hospitals. Some current initiatives in Australia include:
However, simplicity is perhaps still misleading, and the term ‘simplexity’ is more accurate. Simple systems often require greater consideration and this is constrained due to established problem-solving methods in the Australian health and building sectors. Conventional design problem-solving focuses on creating new standards for individual issues and so there is a tendency to provide one-off design solutions instead of developing a brief of issues for seeking greater opportunities for flexibility.
Challenging the use of one-off solutions and developing more over-arching approaches is less common. For example, enhanced levels of sound attenuation demand more stringent ratings between room types. The solution typically requires increasing the resistance of partitions rather than allowing, for example, a modified operational procedure or the use of acoustic masking techniques.
Enhancing accessible change within our hospitals requires a whole-of-industry vision and collaborative effort. Change is more accessible when it is not disruptive, is economical, and uncomplicated. The examples in this short article illustrate some approaches to achieving this without necessarily costing more or compromising quality.
A vision for expedient change must be shared and adopted as a common position by a project team or client. The next instalment in this series will expand on further viable, flexible fabric techniques.
 These six examples are drawn from my recent research artefact: Flexible designs inside hospitals: Cases for value-led design approaches, where a more complete explanation is substantiated by detailed study, practice analysis and expert consultation.
 If measured in an established market. New techniques will require special consideration until they have been accepted in practice.
 Simplexity: Orginal attributed to Blin, P. (2013). Brunet Saunier architecture: Monospace & simplexity. Basel: Birkhauser. Although it was used in a slightly different context, the expression does give an indication that complexity can be conflated with simplicity.
Article by Isabelle Mansour
Isabelle Mansour is a practising Health Planner who has previously worked as a Critical Care Registered Nurse. She currently works for TSA Management (Sydney Office) on capital health projects including major public hospital developments in NSW.
These days innovation in healthcare is a topic of great interest to healthcare professionals, patients and carers. Hospitals are future-proofing their designs to integrate digital innovation into their service models to deliver better and more affordable patient-centred care. Meanwhile, patients are embracing the introduction of technology into their health journey and being increasingly empowered to co-manage their own recovery and treatment in partnership with their clinicians.
In this article, I discuss my personal views as a Health Facility Planner regarding the future-proofing of our health facilities and the workforce required to treat more complex patients in a dynamic digital environment. During one of the Health Design educational forums I attended recently, the speaker shared a thought-provoking comparison between:
Robot-led manufacturing process
Clinician-led surgical procedure
Comparing these two pictures suggests that over the past decade, medicine has been slower to adopt technology compared to other industries. Despite the enormous interest in big-data analytics, integration of patient information, telehealth and artificial intelligence tools, the concept of factory-like hospitals has been slower to be accepted and incorporated in patient care.
Another example of the technological innovations in the design of healthcare facilities can be seen in the Memorial Sloan Kettering Cancer Centre (MSKCC) in New York. The MSKCC is leading the way in designing the futuristic Intensive Care Units (ICUs) and adapting technologies to improve customer experience and the quality of critical care delivery. Their vision for ICUs for the year 2050 includes the design of “biosphere capsules” which will monitor the patients’ environment using advanced sensors, visors to transform and communicate the patient’s thoughts, holographic doctors to provide remote care and other technological innovations which will transform the way medicine is practised.
Biosphere capsule and other technological innovations – a vision for ICUs in 2050?
There is little doubt that the implementation of this type of technological innovation will have significant benefits. These include making it easier for health professionals to monitor patients, reduce the need for excessive wiring of patients and freeing up clinicians in hospitals to carry out more complex cases.
Another captivating topic in the domain of Innovation in Healthcare delivery is the concept of a Virtual Reality Health Service. This would deliver comprehensive clinical care to patients regardless of where they live and what systems are available. The model has been already implemented in NSW e.g., Western NSW Local Health District use telehealth to provide specialist advice to remote areas. The Mid North Coast Local Health District has introduced “Telestroke”, a project that is improving outcomes for patients who present to Port Macquarie and Coffs Harbour Hospitals with stroke symptoms. Telestroke supports the bridging of distances and the delivery of world-class stroke assessment, treatment and management, irrespective of a patient’s location. This is important for rural communities as patients often travel long distances to reach the nearest hospital. That hospital may not have the specialists to treat and manage those patients and must transfer them to other hospitals that may be even further away.
There are multiple advantages associated with the use of technology in healthcare that cannot be overlooked. These include:
Before going too far in designing future healthcare innovations and future-proofing our healthcare facilities to accommodate them, are we truly involving the end-user (patients) in these decisions? Or are we just assuming that if we simply design an innovative hospital or service the “right way” and in compliance with relevant guidelines and policies, patients will undoubtedly embrace it?
Despite the challenges, I believe that the benefits of technology far outweighing the disadvantages. Moving forward, the key is to find the correct balance so that the efficiencies and precision of technology coupled with the human touch are used to provide optimum patient and experiences.
What do you think? Will we ever replace the need for human touch in healthcare? How far should we go using technology to replace the need for human carers?
Article by Dr Jane Repin Carthey
Although the COVID-19 pandemic has been around for most of 2020, it is still so recent that there is relatively little published peer-reviewed literature offering practical solutions for longer-term health facility design responses. However, it is already becoming obvious that a much greater emphasis is being placed on infection prevention and control, and this will affect the design of future health facilities in Australia and other countries. Planners will have to respond to quite specific operational requirements that include testing and streaming of patients based on their COVID status in order to keep other patients and healthcare staff safe from infection. Drawing from the literature, five key issues are discussed in this post regarding health facility design responses to COVID-19 and future pandemics. They include:
Future posts will expand on, and add further findings to this list of resources.
Dietz et al. (2020) detail how to manage the built environment to reduce the spread of COVID-19. They outline the known factors that spread infections, and then some approaches that are useful for reducing the spread of viruses and other infectious agents within the built environment. The factors that may reduce the spread of infectious agents such as COVID-19 include the use of fresh versus recycled air in HVAC systems, correct use of HEPA filters, encouragement of handwashing and mask wearing, reduction in the occupancy of crowded spaces, and ensuring the correct range for humidity and other measures for air quality. They note the particular requirements of health facilities as follows:
“In planning for the future, architects, designers, building operators, and health care administrators should aspire for hospital designs that can accommodate periods of enhanced social distancing and minimize connectance and ﬂow between common areas, while also affording ﬂexibility for efﬁcient use of space during normal operating conditions.” (p.10)
Human Factors and Ergonomics (HFE) is defined as:
“…a discipline that examines the design of individual work system components and the interactions with each other, taking into account human capabilities and characteristics, with the goals of achieving optimum human safety and performance” (Gurses et al., 2020, p. 50).
HFE may be useful in developing workflows, routines and protocols aimed at ensuring the safety of clinicians and patients during a pandemic such as COVID-19. For example, for a patient presenting to an ambulatory care clinic, HFE may assist in developing processes for screening, registration and isolation protocols. Some solutions may be quite quick and practical e.g., appropriate signage while others may take longer and require the input of groups of experts.
Ideally, this work should be done prior to briefing or designing a health facility but some of it may take more time than allowed in the pre-briefing stage. This may be risky in terms of causing the need for re-design, re-documentation, or alterations during or following construction. For example, the use of PPE may require more space allocated for storage, doffing and donning, and this is difficult to provide retrospectively in order to maintain appropriate and safe work practices.
Valika and Billings (2020) outline operational issues that were implemented so that an otolaryngology outpatient clinic could be re-opened in Illinois, USA. During the initial period of high numbers of COVID infections, many surgical cases were postponed, and clinics were conducted using a mixture of limited in-person visits and telemedicine. This is similar to the situation in many hospitals in Australia. Once the pandemic curve began to flatten, the criteria for elective healthcare visits were loosened and the need for a new “normal” that kept patients and staff safe was recognised. Strategies adopted included:
Some or all of these mainly operational strategies have been trialled or used by most healthcare providers. The implications for the provision of physical space and the design of ambulatory or outpatients clinics will include the need to adapt in the future to support these refined care models.
The Nuffield Trust Report (Edwards, 2020) looked in more detail at how healthcare design approaches over the last few decades are impacting on the ability of hospitals to respond to the demands of the current pandemic. Some of the significant or noteworthy points it considers include:
This is a good and detailed summary of factors to be considered in looking to the future design of healthcare facilities for the Australian and other communities. These will be added to in future posts on this topic.
Finally, Sachs (2020) discusses the importance of maintaining access to nature while dealing with COVID-19, and continuing to provide a patient-friendly environment. Given the need to wear PPE while dealing with patients, reminding ourselves of the human element is also important at this time. Sachs questions whether healthcare facilities are now using outdoor space differently than before. For example, she discovered in one facility that staff were using gardens more than ever as respite from the stress and intensity of their daily work. Although patients and visitors were also discouraged from congregating in some outdoor spaces in some facilities, in others there was increased use of outdoor areas – again for stress relief and a break from the intensity of the COVID-19 treatment environments.
She notes that: “…in addition to feeling safer outdoors, people seem to be enjoying the outdoors more. They are discovering the beauty and joy that nature has to offer” (p.3). She finishes her editorial by hoping that this apparently newfound appreciation for gardens and the outdoors continues to be the case post-COVID in the design of healthcare facilities. This is a sentiment shared by many designers and healthcare workers.
Dietz, L., Horve, P. F., Coil, D. A., Fretz, M., Eisen, J. A., & Van Den Wymelenberg, K. (2020). 2019 Novel Coronavirus (COVID-19) Pandemic: Built Environment Considerations To Reduce Transmission. mSystems, 5(2), e00245-00220. doi:10.1128/mSystems.00245-20
Edwards, N. (2020). Here to stay? How the NHS will have to learn to live with coronavirus. Retrieved from https://www.nuffieldtrust.org.uk/resource/here-to-stay-how-the-nhs-will-have-to-learn-to-live-with-coronavirus
Gurses, A. P., Tschudy, M. M., McGrath-Morrow, S., Husain, A., Solomon, B. S., Gerohristodoulos, K. A., & Kim, J. M. (2020). Overcoming COVID-19: What can human factors and ergonomics offer? Journal of Patient Safety and Risk Management, 25(2), 49-54. doi:10.1177/2516043520917764
Sachs, N. A. (2020). Access to Nature Has Always Been Important; With COVID-19, It Is Essential. HERD: Health Environments Research & Design Journal, 1937586720949792. doi:10.1177/1937586720949792
Valika, T. S., & Billings, K. R. (2020). Back to the Future: Principles on Resuming Outpatient Services in the COVID-19 Era. Otolaryngology–Head and Neck Surgery, 0194599820933597. doi:10.1177/0194599820933597
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