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The Guiding Principles of Hospital Design and Planning

In an environment where failure to plan is planning to fail, time and time again I have witnessed the devastating effects poor planning can have on the design and construction of healthcare facilities in both developed and developing markets. Despite the best intentions of providing healthcare to a growing market, the importance of infection control, staff efficiency, hospital workflow, as well as patient safety and comfort are often overlooked.

This seems to occur more frequently when the project is not championed by an experienced healthcare design team, or when the structure is not built to the specific needs of a healthcare facility or healthcare market. Another major issue appears when the wrong stakeholders are asked to advise. People just don’t know what they don’t know. Most hospital CEO’s will experience one major construction project in their career. By contrast, healthcare planning and design firms will build five to 10 a year.

During a recent customer site visit, I was asked to walk through a shell and core building that I quickly realised was never intended to be a hospital. Just by looking at the architectural drawings, I discovered some clear giveaways: a small actual footprint, central core elevators and multiple stories. This building was a hotel. This kind of design makes it difficult to separate inpatient and outpatient flow due to the limited availability of vertical movement options. 

This footprint also impedes department adjacencies or the need to house some departments on a single floor, like radiology and surgical floors. Not every building can be turned into a hospital; a medical facility is a purpose-built structure.

Five Key Principles
In my 34 years in international healthcare, I have had many similar experiences, which have led me to adopt five guiding principles when advising clients in their hospital design and technology planning.

One: Equipment dictates design, design does not dictate equipment. Advisers sometimes forego critical equipment simply because they will not fit within a design or in a shell and core structure repurposed as a healthcare facility. Large, heavy pieces of equipment like MRIs for example, need to be positioned on an outside wall in the structure to plan for delivery and possible replacement. I’ve seen this dozens of times at the cost of several thousands of dollars in reconstruction.

Two: Design today for tomorrow’s expansion. I particularly see a lack in vision in renovations of projects that have been constructed within the last five years, which addressed only current problems and were therefore time-locked. Most communities don’t shrink in population and a good healthcare facility will grow a community around it. 

The healthcare facility must not only address today’s issues but have vision toward future challenges. In this case, growth in number of beds, additional departments and the changing structure of population and healthcare needs should be considered during the planning phase of the facility. A good healthcare facility will last about 30 years or more.

Three: Core is key. I start every design review around four key departments. Emergency Department, Radiology Department, Operating Theatres, and intensive care units. 

My thought process is that each of these departments feed patients to each other so having them in close proximity can reduce patient travel and the need for duplicate equipment. During my imaginary travels from department to department I always keep in mind what I call PDR: privacy, dignity and respect of the patient. PDR can be as simple as providing curtains, walls or doors between patients; not parking inpatients’ stretchers on corridors or public waiting! There needs to be an understanding that many patients can’t choose for themselves, so you will be making choices for them. These considerations will aid in planning the movement of patients from department to department, so they don’t cross with general hospital population.

Four: Solve problems with pen and ink instead of sledge hammers. Talking through, walking through, mock ups, and 3-D renderings are all methods of identifying issues before they become real construction problems. It is important to remember that you will pay for a mistake three times; once to build it, once to tear it down and once to rebuild it. 

Moving into construction without an adequate review process, will increase the likelihood of change orders/variations further down the line. On many projects I’ve reviewed, in the rush to construction, simple mistakes that could have been avoided resulted in tens of thousands of dollars of costly corrections. An example of that is an MR landlocked in the centre of the building and walls that had to be torn down for installation.

Five: Design with caregivers in mind. I apply a rule that a caregiver should never move more than 25m in any direction to obtain the supplies needed to do their job. This is accomplished by locating support rooms to adequately supply the staff. During review of plan elevations, it is important to remember simple rules; like a caregiver should never move their feet with sharps or needles in their hand. Accordingly, locating sharp disposal boxes at the site of injections is a simple measure that has great impact. Another easy fix is to mount patient monitors on articulating arms, which can be adjusted to the height of the caregiver. A nurse’s time should be spent with the patient, not chasing down supplies; so, by simply by locating support rooms within those 25m of where the care occurs can drastically reduce the amount of time a caregiver spends traveling the hallways. I believe strongly that taking care of your caregivers is a great consideration in planning and is accomplished without costly measures.

Optimised Workflows
To address some of these key guiding principles, I developed a detailed Design Review Methodology in the past years. At the heart of this methodology is the need to retain an experienced hospital technology planning team and senior technology planner. 

The overall goal of an experienced Hospital Technology Planning team is to assist in the establishment of international standards in hospital design that support patient safety, infection control and optimised workflows based on room and department placements and functional adjacencies. 

A senior technology planner can provide quick desktop reviews of designs, in depth design reviews and BOQs, in addition to supporting the Client Design Team with the application of best practices in hospital development during the design phase. In addition, the senior technology planner will support the creation of a project plan for technology installation, pre-installation and commissioning needs with their main focus being the hospital as a whole and all equipment from an agnostic point of view.

Out of the hundreds of hospitals I have had the opportunity to work on over the past 30 plus years, I would estimate one third run into trouble; and by having a hospital technology planner at the centre of the discussions you could reduce this number significantly.

Medical facilities are some of the most technically complex building projects in the world and obtaining the right advice is key; and should be applied as early as possible to avoid costly mistakes and making the project a long-lasting success.

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