Changeability inside hospitals

time for change sign with led light

By Dr Harm Hollander

Dr Harm Hollander – eternal student!

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.

Summary

Changing the fit-out for a hospital is commonly hindered in supporting more up-to-date operational models. The difficulties that often stand in the way of upgrading an existing fit-out include the complexity of building works, extensive and contorted construction logistics, high costs, inflexible procurement processes, lack of reusability of materials, and, not least, potential disruptions to operations and clinical service delivery.  By definition, a building is more flexible if it can be changed easily. This article discusses approaches to building design that may better support change.

Towards accessing change

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).

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[1]:

  1. Field installation of floor finishes, continuous under partitions (including matching sealable, skirting coves applied to individual rooms). 
  2. Snap-in/ snap-out door frames (frames that can be removed or installed easily because they support the local parts of the partition itself as well as their own weight).
  3. Use of self-supporting fittings and fixtures (removing the need for bespoke partition nogging construction for wall-fixed fitments).
  4. Contiguous containment ceilings (instead of continuing partitions into ceiling interstitial space to provide acoustic or air barriers, with the result being simplified pre-manufacture and ease of construction between the regular ceiling plane and the slightly deflected floor plane over); 
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. 
  1. Enhanced surveys and record-keeping (augmenting existing practices by use of technology to build credible sources of data that include actual building element positions and deflection information); and
  2. Level floors with minimum set-downs (requiring techniques for creating effective floor drainage, e.g. in ensuite bathrooms using negligible ramping and low-build, grid-drained waterproof screeding).
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[2].  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: 

  1. Alternatives to zonal smoke control (simplifying fire systems and other impacts dramatically); and
  2. Replacing fire hose reels in clinical areas with alternative fire control measures (keeping room designs uniform and universal).

However, simplicity is perhaps still misleading, and the term ‘simplexity’[3] 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.  

Conclusion

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.   


[1] 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.  

[2] If measured in an established market.  New techniques will require special consideration until they have been accepted in practice.

[3] 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.


How do we enable change within hospitals? What should we consider?

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