Hospital Design Principles

Policy and Service Context

Purpose

This document has been developed as part of a suite of guidelines, norms and standards for healthcare facility planners and designers both to indicate specific requirements to be met in the development of new and the upgrading of existing healthcare facilities for the public sector in South Africa, and to provide context for planners and designers. This document focuses on the form of the hospital and is supported and enabled, as indicated in section 2 below, by a range of other more focussed guidelines.

Overview

Hospitals provide the primary setting for the delivery of health care services. For patients the setting is important – patients expect an environment that will enable effective treatment for their condition, that will be pleasant and promote healing and that will be safe. While patient episodes of care are generally infrequent and of relatively short duration, the quality of the environment and experience can significantly influence both their physical and mental wellbeing as well as their rate of recovery. In contrast the hospital environment is the permanent place of work for staff. Their experience must ensure that they are enabled to carry out their duties in the most effective way possible. Good quality environments can positively enable delivery and lead to more effective patient outcomes while poor quality environments can lead to patient and staff frustration, both compromise service delivery and patient outcomes and increase the cost of service delivery.

This document is designed to provide a frame of reference for the planning and design of the whole hospital; at one level it provides the introduction to the suite of IUSS Guides, Norms and Standards (IUSS-GNS) for healthcare facilities, at another it synthesises the common requirements of all documents, providing the glue that links all the many clinical and support departments and services that make up the complex organism that is the hospital.

The Hospital Design Principles Guide is one of a set of 46 work packages making up the suite of IUSSGNS documents. The set of documents was structured into four broad subsets:

• Clinical and clinical support departments where there is direct contact between the patient and hospital staff
• Support departments providing administration, hospital support or facilities management services enabling the primary clinical services
• Cross cutting documents which impact many or all departments, and
• Procurement related documents including toolkits and guides impacting the planning, briefing, acquisition, commissioning, maintenance and decommissioning of healthcare facilities.

Many of these documents are interrelated and in order to avoid duplication information is located primarily in the document related to the primary function. Cross reference is made to documents where topics common to more than one department or unit are covered in more detail. For example specific requirements for infection prevention and control (IPC) will be highlighted directly where applicable, such as in the surgery or out-patient services documents but as IPC is critical across all healthcare facilities, the subject covered more thoroughly and in more detail in the IPC document.

Table 1 below lists the full suite of documents and the key cross reference documents for the hospital design principles document.

Table 1: IUSS guidelines and interdependencies

This document outlines the policy and service context for a hospital project as well as providing detailed requirements and context for planning and design decisions that need to be considered during the development process. The document is divided into 3 main sections:

• Part A outlines the national and provincial service and policy context and briefly covers the key factors impacting on design development
• Part B covers more specific planning and design requirements through the various stages of design development and includes issues common to most hospital departments, while
• Part C includes schedules for further reading and references.

This document is designed to fulfil two primary functions:

• Firstly to act as a primer for healthcare facility planners and designers providing both background and contextual information on hospital design principles as well as references for further reading, and
• secondly to list specific requirements that the design team need to adhere to.

Sections which act as a primer are shown in normal font text, while those serving as specific requirements are highlighted in italic text and are listed under the relevant section.

Policy and service delivery context

Healthcare infrastructure and healthcare systems

The primary function of a health care system is to deliver services that will contribute towards the health and wellbeing of the community served. Facilities are part of the healthcare service system and require a set of allocated resources – including people, buildings, equipment drugs and supplies to operate effectively. The ability of the system to operate depends equally on the quality and effectiveness of the stewardship and oversight and on available and allocated funding.

The make-up of a particular facility depends on the defined service to be delivered as well as services provided from or shared with other related facilities (such as referred clinical services, breakdown and prepacking in the pharmacy for linked clinics or outsourcing laundry services). This must be defined in the project brief.

Figure 1: Health system performance framework

Healthcare facilities provide the environment through which healthcare services are delivered over the full life cycle of the asset. Facilities, usually with a life span of up to 50 years, are the most fixed component and therefore also potentially the most constraining aspect of the health care delivery system. Quality assets can positively enable the service; equally poor facilities can negatively impact service delivery. The more effectively the service is planned, defined and resourced the more likely that individual projects can be developed to provide an effective foil for service delivery. The better and more experienced the team deployed to a new or upgrade project, the more likely the resultant facility will be both enabling and resilient over time.

The context for service delivery for the specific facility that the professional team is tasked on, will be developed from the provincial Service Transformation Plan into the project brief.

Policy

Health service delivery in South Africa is provided under the framework of the National Health Act

Regulations

National Health Insurance (NHI)

Requirements:

A. The design of all healthcare facilities must allow for the provision of the required range of services envisaged under NHI and must be patient friendly, robust and sustainable over their planned service life.

“South Africa is in the process of introducing an innovative system of healthcare financing with far reaching consequences on the health of South Africans. The National Health Insurance commonly referred to as NHI will ensure that everyone has access to appropriate, efficient and quality health services. It will be phased-in over a period of 14 years. This will entail major changes in the service delivery structures, administrative and management systems.” (HST.org.za, 2014) In the service delivery model outlined in the NHI Green Paper (2012) NHI services will be provide through all existing healthcare facilities in South Africa supplemented where appropriate. Services will potentially be delivered from both the public and private sectors with the bulk of services continuing to be provided through the government network of facilities. Significant work will be required to ensure that all facilities can cater for the expanded range of services envisaged under NHI, to bring facilities up to the standards required and ensure that they can be readily and cost effectively managed and maintained at the required standard. Standards will be monitored by the Office of Standards Compliance.

Measuring performance

National Core Standards for Health Establishments in South Africa (NCS)

Requirements

A. Healthcare facilities must comply with the National Core Standards (NCS) set by the Office of Standards Compliance (OSC). As healthcare facilities will be assessed from time to time to review ongoing compliance as set out in the NCS, it is essential that planners and designers are acquainted with these requirements and plan and design accordingly.

The NCS (Republic of South Africa, 2011) were developed by the DoH to assist in setting the benchmark of quality healthcare against which delivery of services can be monitored. It addresses various aspects related to safety and security issues, particularly in the following two sections of the document: Domain 2: Patient Safety, Clinical Governance and Clinical Care covers how to ensure quality nursing and clinical care and ethical practice; reduce unintended harm to healthcare users or patients in identified cases of greater clinical risk; prevent or manage problems or adverse events, including healthcare associated infections; and support any affected patients or staff Domain 7: Facilities and Infrastructure covers the requirements for clean, safe and secure physical infrastructure (buildings, plant and machinery, equipment); functional, wellmanaged hospital services; and effective waste disposal (See Annexure B).

Project assessment

Requirements

A. The most significant impact on the functioning and operation of the proposed service is usually achieved through effective planning and design of the new facility or upgrade project. Generally the more quality time that is invested in project initiation and development the better the outcome will be.

Project plans and designs will be assessed during their development at the approval gates indicated in the Project Implementation Manual and as outlined in figure xx below.

Gateway process

Design assessment framework

Post occupancy evaluation

Performance monitoring

Infrastructure planning context

All healthcare facilities go through a life cycle starting with strategic service and project planning through to eventual decommissioning and disposal. This is illustrated in figure xx below.

Infrastructure classification – facility classification vs levels of care

The classification of health care facilities and levels of care has been gazetted by the national Department of Health^[1]. This shows types of facilities and levels of care. Some specialist services can however be provided at

Levels of care however are often shared across facility types as illustrated in figure xx below.

Document scope

Although many of the background and requirement design principles are similar for different types of healthcare facility, this document will focus on the design of all levels of hospitals. The design principles for clinics and Community Health Centres are covered in the IUSS-GNS document Primary Health Care.

Planning and Design

Enabling healthcare delivery

It is self-evident that hospitals and other healthcare facilities exist because of patients and the need for the delivery of appropriate and fully enabled health care services. The delivery of appropriate care requires a wide array of appropriate services, functional spaces and equipment, as defined in the brief, which provide the primary environment for clinical diagnosis, patient treatment and care. These spaces provide for and are supported by a wide range of clinical, administrative and facilities management systems and support systems that together enable the delivery of clinical care services. The delivery of appropriate care is further enabled, or impeded, by the decisions that are made around the shape, form, layout, flow, relationships, engineering systems, the selection and specification of materials and construction quality of the environment and the ability of the facility to accommodate and support the wide range of clinical, administrative and facilities management support systems that together form the hospital.

Before starting on the planning and design of a hospital project, it is important to understand those key principles that will inform the eventual design of the health care facility. The following principles focussed specifically on patient care and health service delivery are discussed in this section:

• Patient focussed care
• Evidence based design
• Salutogenesis
• Lean healthcare, and
• Hospital systems

A second set of principles, focused on enabling healthcare delivery over the service life of the facility will be addressed in the following chapter.

Patient-focussed care

Requirements:

A. Hospital planners and designers should be acquainted with the broad principles of patientfocussed care and should incorporate the principles into their designs

Patient-focussed (PFC) or patient-centred care provides a reminder that the design of a health care facility and the functioning of the healthcare service need to respond primarily to the needs of the patient. The Australian Commission on Safety and Quality in Healthcare (ACSQH) defines patientcentred care as “care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers. The widely accepted dimensions of patient centred care are respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and carers, and access to care.”^[2]

While most aspects of PFC relate to the care-giving process, these activities are either enabled or constrained by the physical environment and the two need to be seen as wholly interconnected.

ACSQH goes on to note that “research demonstrates that patient-centred care improves patient care experience and creates public value for services. When healthcare administrators, providers, patients and families work in partnership, the quality and safety of health care rise, costs decrease, and provider satisfaction increases and patient care experience improves. Patient-centred care can also positively affect business metrics such as finances, quality, safety, satisfaction and market share.”

The design focus of PFC is to identify those aspects of the physical design and equipping of the patient care environment which can be effectively controlled during planning, design and operational management of the facility.

Research papers and literature on patient focussed care can be found in section 16 of this document.

Evidence based design

Requirements:

A. Hospital planners and designers should be acquainted with the broad principles of evidence based design and should incorporate the principles into their designs

Many of the concepts and objectives highlighted in PFC are consolidated into a hospital design research framework known as evidence based design (EBD). EBD is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes^[3]. This concept initially researched and reported at the University of xxx by Roger Ulrich, seeks to identify all research papers related to the patient experience in hospital that are linked in some way to the physical environment and to draw from these recommendations which will assist healthcare planners and designers to create the right physical environment to support PFC.

This resulting research informed design process is seen as a deliberate process for creating hospitals and other healthcare design buildings informed by the best available evidence, with the goal of improving safety, medical, staff and financial outcomes.^[4] Ulrich also notes that the state of knowledge of evidence based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients and better places for staff to work.^[5]

Specific design requirements that come out of the PFC and EBD environment will be expanded on in later chapters on:

• Evidence based design
• Ergonomics
• Recognising specific populations
• Daylight, lighting and health
• Ventilation
• Infection control

Laura’s slides:

“Research informed design:”  it refers to a

The four components of an Evidence-Based Design Process are:

• gather qualitative and quantitative intelligence
• map strategic, cultural, and research goals
• hypothesize, outcomes, innovate, and implement translational design, and
• measure and share outcomes^[6]. From "

Definition:

Evidence-Based Design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes http://www.healthdesign.org/aboutus/mission/EBD_definition.php

Research papers and literature on evidence based design can be found in section 16 of this document.

Context

Background – hospitals are dangerous places, complex, interface between technology and human caring;

In a comprehensive literature study Ulrich et al searched for links between building design decisions and medical outcome through the patients stay in hospital. The study identified the following key evidence based design areas that the healthcare facility planners and designers need to address:

• Improving patient safety through environmental measures. This can be further subdivided into:

o Reducing hospital-acquired infections

o Reducing medical errors o Reducing patient falls

• Improving other patient outcomes through environmental measures, including o Reducing pain o Improving patients sleep o Reducing patient stress o Reducing depression o Reducing length of stay o Reducing patient disorientation o Improving patient privacy and confidentiality o Improving communication with patients and family members o Fostering social support o Improving patient satisfaction

• Improving staff outcomes through environmental measures o Decreasing staff injuries o Decreasing staff stress o Increasing staff effectiveness o Increasing staff satisfaction

Important to understand hospital acquired infection and possible modes of transmission – refer to IUSS-GNS document Infection prevention and control. Impact on design layout, selection and location of fittings, ventilation, selection of finishes, ...

Salutogenesis

Many of the design concepts developed from patient focussed care are also found in concept of psychosocially supported hospital design proposed by Alan Dilani in turn based on the concept of Salutogenesis (Dilani, 2009).  Salutogenesis⁷, originally conceived by Aaron Antonovsky in the 1970’s, proposes an alternative to the disease based model of incidence based care which focuses on curative based restorative care, instead focussing on those factors that impact on the creation of health, primarily the relationship between health, stress and coping.

This approach of focusing on a positively reinforcing both the lifestyle environment and coping mechanisms can assist with inevitable stress incidences and lead to improved health. WHO defines health as “a state of complete physical, psychological and social well-being; not only the absence of illness”. This links in to the xxx Constitution xxx and the primary objective of the health care system as shown in figure 1, of enabling and support of the health and wellbeing of the population.

Factors that affect health include:

• genetics – heredity, ethnicity
• biological – sex, age, disease
• social – profession, economy, network
• life style – food, exercise, smoking, alcohol
• personality – attitudes, values, emotions, temperament
• risk factors – life events, risk behaviour, nature catastrophes, danger, violence, and
• environment – geographic place, climate, pollutions, social environment, physical environment, design

While the primary focus in healthcare facilities is on the design of the physical environment, other factors in planning include a move from curative to wellness and health promotion centres. More on this concept? In PHC (more than in L2/3?) health promoting centres could include community support services such as community

In common with the concepts outlined in chapter 6.1 on patient focused care, salutogenesis also focuses on

Factors that affect health

Creating socially supportive environments

Places for ’meeting’ and ’contemplation

Music and Health

Daylighting

Art, Culture and Health Perception and Way finding access to green areas for recreation”

Design for positive psychosocial stimuli and restoration

Restorative Environment Nature and Light

”Health is a state of complete physical, psychological and social well-being; not only the absence of  llness!” WHO

Hospital systems

Requirements:

A. Hospital planners must review all systems in the specific context for their project and must define the requirements for each providing sufficient detail both for the design team to understand and create the right environment for service delivery, and for the commissioning team to enable and initiate the service

Hospitals are built around a complex interrelationship of systems that together enable the people, equipment, supplies into a defined environment at the right time to enable a specific healthcare activity to be performed and, after completion, for the space to be recycled for the next activity. These systems need to be defined and managed and require the right series of delivery, storage, process, delivery and recycling spaces and routes through the facility.

At a high level systems require four actions: input, throughput, output with a feedback loop as illustrated in figure xx below:

Figure 3: Systems framework⁸ Hospital systems include clinical

Hospital support systems include:

⁷ Derived from the Latin salus for health and the Greek genesis for origin.

• ⁸ Adapted from Sullivan & Decker, 1998. Effective Leadership & Management in Nursing.
• Catering
• Laundry and linen
• Pharmacy
• Materials handling
• Waste system

Pharmacy system

Pharmaceutical supplies need to be delivered directly to the pharmacy and offloaded into a security cage. Dispensed output is either directly to outpatients (close relationship to OPD essential, figure xx), delivered to point of use clinical departments – define whether top, or collected by staff from the pharmacy (e.g. ward prescriptions). High level security of the pharmacy and security on delivery routes is essential. Full details are contained in the IUSS GNS document Pharmacy.

Waste system

Provision must be made for the safe collection and holding of waste at point of generation, waste collection and removal to a central holding point, and disposal from the site. Waste disposal pathways should as far as possible be separated from patient and public pathways. In larger facilities this may involve separate service corridors and lifts. Full details of waste management system options and requirements are included in the IUSS GNS document Infrastructure Design for Waste Management in Healthcare facilities.

Lean healthcare

Developed and widely applied in the industrial sector, lean thinking has more recently been applied in the health sector⁹. Application can be both in the delivery and management of healthcare services as well as in the planning, design and construction process for healthcare facilities. This latter will be discussed in more detail in section 8.2 following.

Simply put lean thinking means using less to do more¹⁰. Lean thinking is applied through a structured review of  

⁹ Lean Health Care: What Can Hospitals Learn from a World-Class Automaker? Kim CS, Spahlinger DA, Kin JM, Billi

JE. Society of Hospital Medicine. Published online in Wiley InterScience. 2006.

¹⁰ Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005.  

Developed from the relentless dedication by Toyota towards quality improvement in everything it does, lean production is based on a programme of focused continuous improvement working through efficiency gains, waste reduction, increasing product quality and respect for people. The end result for Toyota is a learning organization that values employee contributions and continuously strives to produce products of higher quality at lower cost. These lean concepts have since been applied in many industries and more recently been brought into hospital planning, operation and management.  

Lean healthcare

As indicated above hospital and clinical systems can be reviewed in terms of ‘input, throughput, output’ equation. Applied in the healthcare environment, Toyota’s Value Stream Mapping (VSM) process can be used to represent the key people, material, and information flows required to deliver a product or service in order to distinguish between value-adding and non–value-adding steps. Significant improvements reducing medical errors, containing costs and minimising the impact of staff shortages have been recorded^[1]. In developing new facilities planners should review existing processes

“lean thinking”? Simply put, lean means using less to do more. (IHI p2) objective  to streamline processes, reduce cost, and improve quality and timely delivery of products and services

Enabling life cycle efficacy

Affordability and life cycle

Requirements:

A. Hospital planners and designers need to develop projects which offer an optimum balance between capital cost and life cycle costing of the operation of the healthcare service. Healthcare service operation includes both the provision of the clinical service, the supporting and enabling services as well as the cost of the management and maintenance of the physical facility and healthcare technology. 

Capital projects are not an end in themselves. A key consideration during the development of a project must be the cost and ease of operation over the full life cycle of the facility. The initial capital cost over the service life of the facility plus reinvestment for upgrades and renovations amounts to some 5-10% of the total life cycle cost incurred through the asset (ref). Healthcare technology costs, while initially only some 20-50% of the capital cost of the buildings, can equal or surpass that of the buildings over the service life of the asset as replacement of clinical equipment generally occurs at a far faster rate than building components. Figure xx below highlights the cumulative costs incurred through the operation of a healthcare facility over its life cycle. The scale of the vertical axis is dependent on the size and type of facility. As a rule of thumb operational costs equal capital costs after about 3 years of service operation.

The initial planning and design phase offers a unique opportunity to create the right environment to positively enable and support health service delivery through the operational life of the facility. It is critical to ensure that adequate time and resources are assigned to the initial planning and design development process. Key planning decisions include the size and type of service....

Sound lifecycle based decisions – for both engineering systems and detailing and materials – can also significantly impact the facility maintenance and management costs through the lifecycle of the facility.