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
Evidence for the impact of place
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.
The Research-Practice (R-P) gap
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.
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.
An explanatory innovation framework
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.
The Australian Health Design Council is proud to announce the winner of the 2022 Health Design Scholarship as Katharina Nieberler-Walker who is undertaking a PhD at Griffith University, QLD, investigating Therapeutic Hospital Gardens. Katharina has previously published a well received article in this blog – see it here. Designing Therapeutic Hospital Gardens (THG) Globally
The AHDC Scholarship Committee was very pleased at the quality of the applicants for this inaugural scholarship with five high quality applications received. We hope that this scholarship scheme will support the creation of future research of use and interest to Australian and New Zealand hospital designers/health facilities.
We plan on showcasing each of the applicants’ work in future blog posts and we encourage you to read and respond as these are published.
We also also encourage all researchers to consider undertaking post graduate research studies – PhD (or equivalent) or Masters by Research at Australian or NZ universities in the future. Conditions of the scholarships require that applicants be Australian or New Zealand permanent residents or citizens so that the research knowledge generated remains local and of use to our specific health systems. We also prefer that students be in the earlier phases of their studies such as at Confirmation for PhD students or similar milestones for other research programs.
The scholarship program allows for up to $5,000 per annum for three years (total $15,000) for PhD or equivalent students or a one-off payment of $5,000 for a Masters by Research student. All in AUD.
Interested applicants must demonstrate the relevance of their research to health building design and we require that the supervisory team should include a member with architectural or other health building design qualifications and experience. Applicants must also be financial members of AHDC.
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 as a tool for health and well-being vs the sterile clinical setting
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.
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.
Creating a design framework for THGs
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.
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.
The need for transdisciplinary research for THG design
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.
Systematic Literature Review
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.
Next Steps: My primary research and its expected outcomes
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 at:
Katharina Nieberler-Walker DipIng (FH) AILA Fellow RLA MPIA PhD Scholar | Griffith University Director | Australian Institute of Landscape Architects (AILA)
Creating environments that assist in reducing stress and avoiding burn-out in staff.
Alison Huynh is a Sydney-based architect specialising in design for healthcare, mental health, master planning and urban design strategy for hospitals.
Understanding the impacts of stress and burnout
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].
Understanding the workplace
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.
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.
Now, more than ever, we need to consider how to improve support for staff wellbeing to enhance job satisfaction, reduce burnout and improve patient care. Fortunately, designers have powerful tools for ameliorating the environment and creating opportunities for staff wellbeing.
Design for quality respite
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.
Design for quality learning
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.
Adaptable planning to support staff needs
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.
Spaces for staff respite and learning don’t need to be large or expensive, simply thoughtful and well-designed. It is the attention to detail and appreciation for the human experience which encourage positive interactions with the environment.
[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
[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
Dr Jane Repin Carthey is an architect and researcher with over 35 years in the health design industry. She was recently awarded a Doctorate of Creative Industries from QUT. She founded the Australian Health Design Council in 2012 and was its inaugural chair. She now manages this research blog and continues to undertake short term design and academic research contracts in the health design space.
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.
Literature – an overview
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.
American Society for Microbiology (USA)
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. https://doi.org/10.1128/mSystems.00245-20
Emergency Medicine Journal, (USA)
Noble, J., Degesys, N. F., Kwan, E., Grom, E., Brown, C., Fahimi, J., & Raven, M. (2020). Emergency department preparation for COVID-19: accelerated care units. Emergency Medicine Journal, 37(7), 402-406. https://doi:10.1136/emermed-2020-209788
Health Environments Research and Design Journal (HERD) – US/international
Hercules, W. J., Anderson, D. C., & Sansom, M. (2020, 2020/07/01). Architecture—A Critical Ingredient of Pandemic Medicine: An Open Letter to Policy Makers. HERD: Health Environments Research & Design Journal, 13(3), 247-252. https://doi.org/10.1177/1937586720928432
Journal of Patient Safety and Risk Management, (USA)
Gurses, A. P., Tschudy, M. M., McGrath-Morrow, S., Husain, A., Solomon, B. S., Gerohristodoulos, K. A., & Kim, J. M. (2020, 2020/04/01). Overcoming COVID-19: What can human factors and ergonomics offer? Journal of Patient Safety and Risk Management, 25(2), 49-54. https://doi.org/10.1177/2516043520917764
Kai Tiaki: Nursing New Zealand
Sutton-Smith, L. (2020). Planning for a COVID-19 crisis. Kai Tiaki : Nursing New Zealand, 26(4), 26-27.
La Radiologia Medica (Italy)
Ierardi, A. M., Wood, B. J., Arrichiello, A., Bottino, N., Bracchi, L., Forzenigo, L., Andrisani, M. C., Vespro, V., Bonelli, C., Amalou, A., Turkbey, E. B., Turkbey, B. I., Granata, G., Pinto, A., Grasselli, G., Stocchetti, N., & Carrafiello, G. (2020). Preparation of a radiology department in an Italian hospital dedicated to COVID-19 patients. La Radiologia Medica, 1-8. https://doi.org/10.1007/s11547-020-01248-1
Scandinavian journal of trauma, resuscitation and emergency medicine, (Scandinavia)
Nadarajan, G. D., Omar, E., Abella, B. S., Hoe, P. S., Do Shin, S., Ma, M. H.-M., & Ong, M. E. H. (2020). A conceptual framework for Emergency department design in a pandemic. Scandinavian journal of trauma, resuscitation and emergency medicine, 28(1), 118-118. https://doi.org/10.1186/s13049-020-00809-7
Patey, C., Asghari, S., Norman, P., & Hurley, O. (2020). Redesign of a rural emergency department to prepare for the COVID-19 pandemic. Canadian Medical Association. Journal, 192(19), E518-E520. https://doi.org/10.1503/cmaj.200509
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.
The importance of design and buildings to the management of COVID-19;
Forward planning of the health service to cope with after-effects of the pandemic including the need to do non-urgent surgery, screening tests, etc;
Staff capacity and training needs;
Preparing buildings to cope with the next pandemic;
Moving care closer to communities – with more outpatient functions/facilities and more services available in the home;
Review of capital budgets.
PPE – donning and doffing procedures;
Isolation rooms – need for more with negative pressure;
Providing 100% single rooms (or ability to effectively cohort);
Reduce crowding with more space to allow physical distancing;
Air conditioning – indoor air quality is extremely important to prevent infection spread;
Research needed into materials less likely to harbour germs or to spread infections e.g., copper.
Flexibility and adaptability
Circulation space to be adequate to allow for physical distancing;
More floor area per patient may be needed;
Waiting room redesign – bigger or smarter? Or none at all?
Pre-fab / modular solutions to reduce construction time;
Pop-up facilities to assess and stream patients pre-admission;
Flexible use of clinical spaces to allow expansion of e.g., ICU or ED into adjoining areas;
Re-think use of administration space – with many people working at home – will this continue into the future?
Virtual e.g., use of telehealth;
AI – remote monitoring of patients;
Space for accommodating and using these technologies – may increase, decrease or change.
Patient experience / avoiding staff burnout
Mental health issues – ICU-related, staff working in PPE all day, stress and anxiety;
Access to nature, views, sunshine and fresh air;
Relaxation/stress reduction in areas away from the workplace;
Food provision for patients, staff and visitors (with so many food outlets closed);
Salutogenesis / biophilia is more important than ever.
Management of resources in possible weakened economies
Climate change – strategies to address may become more important;
Control energy use.
There will be another pandemic! We need to be better prepared…
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.
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:
Field installation of floor finishes, continuous under partitions (including matching sealable, skirting coves applied to individual rooms).
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).
Use of self-supporting fittings and fixtures (removing the need for bespoke partition nogging construction for wall-fixed fitments).
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);
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
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).
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:
Alternatives to zonal smoke control (simplifying fire systems and other impacts dramatically); and
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’ 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.
How do we enable change within hospitals? What should we consider?
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:
A factory where multiple robots are involved in the production process, with minimal human intervention.
An operating theatre, involving a number of clinicians, performing a surgical procedure on a patient.
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.
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:
robots performing surgery that may reduce the risk of human error;
automated pharmaceutical dispensing machines that may limit medication administration errors and promote efficiency;
the use of telehealth to foster equity of access to advanced and timely medical care, and
digitised health records that enhance patient care by improving clinicians’ access to big data, etc.
However, are we ready to fully rely on machines and let the virtual world completely take over from human beings in delivering patient care?
Are we overlooking the importance of human touch in the recovery and healing process – both physically and emotionally?
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?
Designing the healthcare environment to respond to the threats from COVID-19
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:
Characteristics of the built environment affecting the spread of infections such as COVID-19.
Using Human Factors and Ergonomics (HFE) to develop operational procedures for achieving optimum human safety and performance – in particular triaging and assessing COVID-era patient presentations.
Operational issues to be considered in reopening and running outpatient and ambulatory facilities in the COVID-19 era, including the impact on the built environment
A summary of key findings from the Nuffield Trust Report into the NHS with recommendations regarding how healthcare buildings can assist with responding to infectious diseases and pandemics such as COVID-19.
Maintaining patient-friendly environments by accessing nature, with concurrent and appropriate infection control measures in place to manage threats from COVID-19 and other possible future pandemics.
Future posts will expand on, and add further findings to this list of resources. Please follow the blog by scrolling to the bottom of this post, and clicking on the “Follow” button. You will be notified as future posts are published. We also encourage your feedback on this and other posts. Please let us know what would be useful subjects for us to address in future posts.
Characteristics of the built environment affecting the spread of infections such as COVID-19
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)
Using Human Factors and Ergonomics (HFE) to achieve optimum human safety and performance
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.
Operational issues to be considered in reopening and running outpatient and ambulatory facilities in the COVID-19 era, and the impact on the built environment
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:
Creating team-based models focusing on sub-speciality lines of care with less crossover between teams including use of clinic rooms and treatment areas;
Contacting existing patients regarding their interest on keeping or rescheduling outpatient visits – enabling the teams to focus on scheduling new patient visits;
Maintaining social distancing;
Incorporating telemedicine wherever possible;
Establishing protocols for PPE use during procedures;
Pre-screening patients before their visits;
Revising the practice of double-booking appointments to single appointments and greater use of telemedicine – in order to enable more compliance with social distancing within waiting rooms.
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.
A summary of key findings from the Nuffield Trust Report into the NHS in early 2020
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:
Design Issues such as hospital accommodation requirements and layout:
Designing for “loose fit” and generous circulation space. This is contrasted with the elimination of extra space to reduce cost which has been occurring over the last few decades. This is similar to the Australian experience driven by the use of design guidelines and efficiency measures for circulation, travel, etc;
Providing a majority of single patient bedrooms – a direction that Australian hospitals are embracing, although not yet fully achieved;
Where it is not possible to have all single rooms, which may be the case in older or rural hospitals, cohorting patients in shared accommodation in terms of whether they are high or low risk in terms of COVID or other infections could be pursued;
Making corridors wider to keep flows separate and to allow for distancing especially when transferring patients from one part of a hospital to another. In Australia, it may be necessary to test whether the 2.4m corridors required by the design guidelines serve this purpose;
Emphasising the need for Personal Protective Equipment (PPE) including more space for donning and doffing PPE, and more handwash basins generally in-patient care areas. This is difficult and expensive to provide retrospectively without compromising other functions such as storage or circulation paths;
In Emergency Departments ensuring adequately sized waiting rooms to allow for social distancing plus more isolation rooms and single rooms depending on how patient flows are managed within the department;
Providing places for people to buy and consume food safely while social distancing.
Separating operational and clinical flows for infectious patients in all departments;
Noting that parallel or duplicated assessment units may be required, and this will require more staff, although telehealth may be used in outpatient areas for this purpose;
Segregating infectious patients within Intensive Care Units (ICU) is critical, and this is already happening.
Demand issues and capital investment:
To address increased demand for ICU beds, other spaces may need to converted to ICU functions e.g., operating theatres, recovery spaces, endoscopy units although clearly this cannot be a long-term solution when normal healthcare services resume. Flexibility and adaptability in design and fit out are required to be able to repeat this, if necessary, in the future;
Additional capital investment may be required to support the separation of flows for infectious and non-infectious patients through a hospital e.g., extra Medical Imaging capacity may be necessary, more or larger waiting areas, more and bigger lifts to cope with social distancing, and to promote direct access to facilities and services in multi-storey buildings without mixing patient groups or infectious with non-infectious patients;
It may be necessary to run hospitals at lower occupancy rates e.g., 75-80% as opposed to 90% or greater which is often the target at present. This may require more beds than presently provided and may argue against bed reductions in Australia and other countries;
Reduced volumes of elective care in the public sector may see an even greater use of the private sector for this in the future.
Diagnostics, tests and screening:
The need for Point of Care pathology testing will be increased for high risk services such as ENT, Ophthalmology, Oral Surgery and Endoscopies;
Greater need overall for diagnostic services;
Current reductions in presentations for routine tests and screening (such as BreastScreen, Bowel Screen, etc) will eventually create a backlog that will need to be managed and spread out so as not overwhelm staff or other resources.
Greater shifts to use of telehealth and telephone consultations may reduce need for traditional clinic rooms but increase the need for greater IT support and spaces to make these calls or hold that type of meeting.
Presentations, screening and streaming:
Considering how to manage people presenting at EDs perhaps by insisting on the use of GP or other clinical referrals – as occurs in Denmark, Norway and the Netherlands;
Define some hospitals as “Covid-free” as happened to some extent in China – this may not be possible in rural or regional areas where there may be only one or, at most, two hospitals;
“Streaming” within hospitals of patients and staff e.g., designating “infection-free” areas, separate buildings, defining different routes through the hospital, involving the private sector in this streaming approach;
Separating emergency and elective activity to different sites to reduce risks of cross-contamination;
Centralising services even further e.g., paediatrics to manage risks to those patient groups.
Other Health Delivery Issues:
There will be impacts on primary care, which we are already seeing in Australia with reduced demand due to people postponing non-critical care including check-ups, etc. Sooner or later pent-up demand will need to be addressed.
There will also be effects on rehabilitation services especially in the community and social care generally. Many of these services are used by high risk patients e.g., older people or those with co-morbidities. Consider the impact of this on care delivery and the use of physical facilities especially where these are centralised or part of a larger hospital campus.
Post-Covid services will be needed to assist with multi-system rehabilitation needs such as pulmonary follow-up for patients with lung fibrosis or those needing psychological interventions following a stay in ICU.
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.
Maintaining patient-friendly environments by accessing nature
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
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
Please comment or add further examples from your experiences to share with others…
By Professor Julie Bernhardt, Dr Ruby Lipson-Smith, Dr Aaron Davis
Julie is Professor of Neuroscience at the Florey Institute of Neuroscience and Mental Health and has a background as a rehabilitation practitioner. Julie is passionate about the role of the built environment in healthcare and about combining the evidence-based practice of neuroscience with design. ORCID 0000-0002-2787-8484
Ruby is an environmental psychology researcher and leads several projects within NOVELL Redesign. ORCID 0000-0002-1702-814
Aaron is an architect by training and an expert in living labs and co-creation. He leads the NOVELL facilitation team and helps us to meaningfully engage with our co-researchers. ORCID 0000-0002-1477-7406
Conversations spark ideas…
Diverse views, experiences and opinions make these conversations richer and bolder. As a clinician and a neuroscientist, Professor Julie Bernhardt began the Optimising Health Environments Forums at The Florey Institute of Neuroscience and Mental Health in Melbourne in 2013 because she wanted to meet people from a diverse range of fields who were interested in built healthcare environments. For Professor Bernhardt, healthcare environments should be considered part of our ‘intervention arsenal’ to improve patient outcomes, not simply a space in which care is delivered.
She hoped to have robust conversations about how we might work collectively across multiple fields of neuroscience, research, clinical care, building planning, designing and execution to optimise healthcare environments. Recognising the challenges inherent in trying to innovate during the designing and building of commissioned healthcare spaces, Professor Bernhardt and a team of likeminded clinicians and researchers decided to focus on creating an innovation project, grounded in research with a strong stakeholder engagement focus to redesign a healthcare facility and service.
Some time later, NOVELL Redesign, or the Neuroscience Optimised Virtual Environments Living Lab, was born. The demonstration project of NOVELL Redesign explores rehabilitation spaces for people with brain injury, especially stroke, because as a group, we know a lot about this aspect of healthcare.
The project team
The core project team includes experts in Neuroscience, Architecture, Rehabilitation, and Living Labs from the Florey Institute of Neuroscience and Mental Health, Swinburne University, Griffith University and industry partners including Silver Thomas Hanley (STH) Health Architecture. We work with a broad range of experts and collaborators from across Australia and the world.
As a Living Lab, stakeholder engagement and the bringing together of diverse groups of people is central to NOVELL Redesign. To this end, we are assembling a team of co-researchers, that range from people who have worked in rehabilitation environments, to stroke survivors with lived experience and their families, and designers and architects who shape the world around us. We are working with people who are interested in the healing power of sensory garden experiences, with people who help others find their way by wafting scents through the air, and with people who are passionate about improving the experience and outcomes of rehabilitation processes and facilities.
Our team are always looking for opportunities to engage, and to bring together diverse groups to build fascinating and insightful collaborations. If you’re interested in finding out more or in getting involved, drop us a line through our website or follow us on twitter.
The NOVELL Redesign project is funded by the Felton Bequest and the University of Melbourne and has four main aims. These are to:
Optimise stroke rehabilitation through design
Develop technology, education and research opportunities
Create strong partnerships between government, healthcare, industry, academia and community, and
Generate a new and rigorous design process guided by a Living Lab framework.
The Living Lab concept
We are using the concept and framework of the Living Lab because the questions we are trying to answer are incredibly complex and can’t be tackled through traditional research processes. Here are just a few of the reasons why it can be difficult to create innovative designs in healthcare:
Complexity: Hospitals are complex places, with intricate and sometimes rigid clinical processes, all of which must be supported by the building in which they are housed. There needs to be a match between the processes and the building – it would be counterproductive to innovate the building without also changing the processes.
Multiple user groups: As any healthcare architect will tell you, every hospital must be designed to satisfy multiple user groups, including healthcare planners, policy makers, clinicians, patients, and families. Sometimes these user groups have conflicting priorities, but all need to be met.
Cost: Every hospital must be built within a (usually tight) budget and timeline, which often doesn’t leave much wriggle room for out-of-the-box or innovative thinking.
Information silos: It’s difficult to learn from past design projects. Post-occupancy evaluations aren’t always conducted and, if they are, are often not made public. There is also often a translation gap between healthcare research and design practice, made more difficult by the tight timelines mentioned above.
The Living Lab methodology can help us to address these problems by giving us a space where we can explore, and where we can dare to think differently. By (temporarily) setting aside some of the roadblocks, we can see what happens when we bring together a rich variety of co-researchers, experimenting and exploring using a ‘yes, and’ mindset rather than defaulting to ‘no, because’.
Starting a living lab during a pandemic
As with just about everyone, everywhere in the world, we had to pivot and adapt to working in the time of COVID-19. For a Living Lab, the inability to meet face-to-face presented a unique and very significant challenge, but our facilitation manager Dr Aaron Davis was able to lead our transition to a digital model of engagement. This meant building interactive online activities that we could work through with our co-researchers both in real-time in virtual workshop sessions, and asynchronously for those who were not able to participate in the fast-paced digital workshop environment.
The workshops built on past research of NOVELL researcher Dr Ruby Lipson-Smith, and explored concepts of safety and security, navigation, adaptability and flexibility, and blurred boundaries. You can see a short time-lapse of the activity in one of our workshops here.
We have had rave reviews about the process and are so excited that this is just the beginning of bringing everyone together to tackle this unique challenge. With any luck, in 2021 we hope to be able to meet each other face-to-face to continue the rich and exciting conversations we have started, but know that the digital collaboration skills we have developed are also invaluable.
Next steps – designing and testing in a virtual environment
Now that our Living Lab is established and growing, our next step is to begin the design and innovation process. We’ll be running a co-analysis process with our co-researchers in the first half of 2021 to organise and synthesise all the information that was generated in our virtual workshops.
This will culminate in the definition of an experiential design brief for stroke rehabilitation facilities which we will use to design immersive virtual prototypes that can be tested through computer modelling, and with a broad range of potential users and stakeholders. We’ll use the feedback we gather to refine the designs, before we bring them back to re-test again in an iterative design innovation cycle.
Ultimately, we are hoping that the insights we gain along the journey, as well as from the final prototype(s), will help to inform and radically shift the way we conceive and construct rehabilitation environments both in Australia and internationally.
Why are we focusing on stroke rehabilitation environments?
Stroke causes a loss of blood supply to the brain, and, if not treated immediately, can result in death or severe disability (do you know how to recognise a stroke – remember to think F.A.S.T). There is predicted to be 1 million Australians living with the effects of stroke by 2050, and, after they have received acute care, many of these people will need some form of rehabilitation. The purpose of rehabilitation is to help people who have had a stroke to live a full life; to regain the skills or abilities that they may have lost as a result of stroke (e.g., re-learn to walk, talk, or use their arm), or to learn to adapt to their changed abilities (e.g., learn to use a walking frame).
While in rehabilitation, stroke survivors are encouraged to participate in repetitive practice – working to build new connections in their brain. Stroke survivors are also encouraged to be physically, cognitive, and socially active, as this can help brain recovery.
Rehabilitation is a unique and under-researched healthcare environment. Most of the past research and innovation in healthcare design has focused on acute care environments such as surgery or intensive care. People in acute care are often confined to bed, and the clinical priorities are diagnosis, infection control, bed rest, and ensuring that vital signs are stable.
In rehabilitation, however, patients are more alert and are required to be active, motivated participants in their care. The findings from acute healthcare contexts therefore might not be applicable in rehabilitation. We therefore chose stroke rehabilitation environments as the first demonstration project for the NOVELL Redesign Living Lab process.
Partner with the NOVELL Redesign project
Living Labs are all about working together. We welcome partners and co-researchers from industry, academia, government, and the community who are interested in contributing to the project, and in making rehabilitation environments better and more effective places.
If we’ve sparked your interest in joining us, or you’re curious to learn more, remember to get in touch via our website or on twitter.
Dr Rhonda Kerr has more than 35 years experience in health economics, health service and facilities planning. Her Ph.D examined the connection between funding for hospital buildings, medical equipment and systems with the effectiveness and efficiency of hospital services.
Australians involved in healthcare, and particularly hospitals, watched with growing concern as American and European hospitals were overwhelmed with patients arising from the COVID pandemic. We wondered how well our hospitals would cope when the pandemic came to Australia. COVID-19 has shone a light on weaknesses in many systems. What are the weaknesses in Australians hospitals? Clinicians required PPE for safety due to the “the constraints of the built environment, including the ageing infrastructure of most hospitals”. After PPE and staff the concerns included:
Are there enough hospital beds for the number of patients?
Are there enough ICU beds?
Was there sufficient medical equipment including ventilators and monitoring equipment?
Are clinical information systems, data systems and digital communications sufficient?
These questions relate to the quality of planning and the quantity of capital invested in public hospitals. Concerns about these factors prompted the government to close private hospitals to gain additional beds and ICU beds in particular. So, would a system where every hospital had a continuous source of capital funds to improve and upgrade facilities and equipment provide a better basis for meeting the challenges for hospitals post-2020? So far border controls and good public health practices prevented our worst fears being realised, but what does the pandemic highlight as we fund, plan, build and equip hospitals?
Is our capital funding model right?
Health Architects maintain form follows function however in my experience it is also true to say form follows finance. Hospital building projects are defined by their funding systems and budgets. My doctoral research assessed the funding needed to deliver the facilities, equipment and systems for effective and efficient clinical services in contemporary Australian hospitals.
We need to change the ineffective and outdated funding model for hospitals
My findings identified an Australian hospital capital funding system that:
prioritises hospital projects in annual funding rounds and electoral cycles with only 14% of hospitals receiving capital funding over 4 years,
is funded at below asset replacement levels averaging 40% of depreciation,
varies significantly between States,
is not directly aligned with current clinical or hospital standards,
results in unequal access to clinical services, and
does not provide for consistent system-wide technological and clinical change.
Our system of funding hospitals does not effectively fund patient access to appropriate care in efficient hospitals . Assessing the effectiveness of capital funding for Australian public hospitals compared with other OECD nations confirmed that the current system ranked below average for comparable nations. Nations that fund every hospital for the capital cost of the patients they treated (or Activity-Based Funding) provided better patient access and greater efficiency . Australia has successfully used Activity-based Funding for operational costs in hospitals since 2013 [3, 4] but our system of capital funding has not progressed for over 50 years.
Should we plan and build more of the same?
Yes and no.
The system of capital funding in Australia has caused inequality of access to acute services and medical equipment. Patient access to appropriate facilities and equipment has been a key issue during the pandemic. Indeed, patient access is the most important of several measures of effectiveness for Australian public hospitals (Public Hospital Performance Indicator Framework). Inequality of public hospital distribution was a theme emerging from the 13 major qualitative reviews of health services this century. Key themes found for investment levels were requiring (i) more investment (n=7), and (ii) improved alignment with clinical requirements and standards (n=4). Access for indigenous and rural residents and funding for innovation were also referenced (n=4) [6-17].
In the critical area of medical equipment, a Senate review found poor access to medical imaging for some metropolitan areas and rural areas resulting in poorer care, particularly for trauma and stroke patients , p.14. There is insufficient planning for the replacement of medical equipment . No prioritised list for equipment replacement exists and there are concerns regarding “transparency and rigour in how high value medical equipment replacement decisions are made” , p.6. For NSW, there was an absence of an effective funding model for medical equipment [21, 22].
The changed lifespan of medical equipment affects buildings
The expectation of increasing precision in clinical practice is reducing the effective lifespans for some medical equipment (by from 10 to15 years) as resolution of images fails to meet contemporary standards  p.69. Similarly, medical equipment and technology changes are making some facilities redundant earlier than planned [23-25].
Analogue hospitals in a digital age
The absence of a national system of funding for digital medical records and contemporary information systems in hospitals is acknowledged as causing patients harm [26, 27]. A range of emerging technologies offer clinical improvement that are appropriate, sustainable and fit with clinical requirement [27, 28].
But currently, there is no process for funding the capital required for the implementation of the next generation of technologies . These include, but are not limited to, artificial intelligence (AI) as a clinical aid [30, 31], wearable devices with real-time physiological outputs [28, 32, 33], Big Data [26, 28], precision and genomic medicine [28, 34].
The pandemic has changed expectations of hospitals from clinicians (who expect to have their personal safety embedded in hospital planning), politicians (who cannot risk infectious outbreaks in hospitals) and the community (who expect access to appropriate care when it is needed). To deliver these expectations when infectious disease is uncontrolled may require:
emergency department bays with solid barriers between patients and specific ventilation solutions,
additional PPE, cleaning and waste management spaces,
single bed patient rooms with ensuite bathrooms to replace shared wards and bathing facilities,
larger staff lunch and training rooms with access to fresh air, as early evidence suggests staff areas have been the sites of significant transfer of infection amongst clinicians,
access to outdoor areas from the wards, imaging, ICU and ED areas for staff mental health stress release,
transparent barriers between patients in ICU,
enclosed office areas replacing hot-desking in confined spaces,
replacing small staff change rooms with larger work clothes distribution systems,
segregation of staff and public amenities for management of community to staff infections,
more diagnostic equipment, and larger equipment stores and cleaning areas in clinical areas, and
greater use of embedded information systems and centralised real-time monitoring of patients.
These changes to hospitals have costs and will need to be available for all clinicians and patients. All patients will expect access to high-quality contemporary clinical care, as our Medicare system guarantees. So we need to consider how to effectively and efficiently deliver the required changes.
What is effective capital funding for contemporary clinical practice?
Effective capital funding to ensure patient access to appropriate clinical care in efficient Australian hospitals would be:
equitable, timely, flexible and readily available  
aligned with the contemporary Australian clinical standards, based on verifiable data, sustainable and at the patient level [6, 8, 22, 37, 38].
A national activity-based system of capital allocation based on clinical guidelines and diagnosis groups has been assessed as superior to the current system of capital funding allocation using the Public Hospital Performance Indicator Framework adapted for capital. Using the existing mechanisms for funding operational costs for hospitals a discreet separate fund for capital could be paid to each hospital. As with the system of funding for operational costs, capital costs would be shared by the Commonwealth and the states and territories for each group of patients with the same diagnosis. This would allow continuous and specific improvement of facilities, medical equipment, technologies and systems.
Where to from here?
In summary, the pandemic has accelerated changes already happening in major hospitals. The difference is that safer hospitals are required for all patients and all staff. A national system of capital funding is the only method to achieve national improvement in safety and access to appropriate care. The old State funded project-by-project system for funding hospital is no longer fit-for-purpose. To make Australian hospitals fit-for-purpose beyond 2020 requires investment for every patient at Australian clinical and hospital standards.
This research has been formally examined as a doctoral thesis but is awaiting publication.
15. Australian and New Zealand Intensive Care Society, ANZICS Centre for Outcome and Resource Evaluation Annual Report 2017. 2017, Australian and New Zealand Intensive Care Society( ANZICS): Melbourne https://www.anzics.com.au/annual-reports/.
22. Garling, P., Final Report of the Special Commission of Inquiry. Acute Care Services in NSW Public Hospitals. 2008, NSW Government: Sydney. p. 30.
23. Diez, K.L.K. Infrastructure Planning for hospitals in relation to a primary portfolio strategy. in Better Healthcare through Better Infrastructure. 2010. Edinburgh Scotland.: HaCIRIC Tanaka Business School University College London.
24. Sun, P.P., An Integrated Project Delivery Process, in The culture for the future of healthcare architecture. Proceeedings of the 28th International Public Health Seminar, R. del Nord, Editor. 2009, Alineaa Editrice,TESIS Interuniversity Research Centre.: Florence, Italy. p. 133-140.
25. Schinko, T.L., H., Strategic design of hospitals by life-cyles, in Health for all Cultural, Operational and Technological Influences 35th UIA/PHG International Seminar on Public Healthcare Facilities. Dalian, China 2015, R. del Nord, Editor. 2016, TESIS Inter-university Research Centre,: University of Florence, Italy.
33. Phillips, B., New series: making the digital health revolution. MJA Insight, 2018(42 29 October 2018).
34. Williamson, R.A., W. Duckett, SJ. Frazer, IH. Hillyard,C. Kowal, E. Mattick, JS. McLean CA. North, KN. Turner, A. Addison, C., , The Future of Precision Medicine in Australia.Report for the Australian Council of Learned Academies,. 2018, Australian Council of Learned Academies (ACOLA): https://acola.org.au/wp/wp-content/uploads/PMED_full.pdf.
35. Duckett, S., Capital Decision-making. The need to change a building block of healthcare., in Capital Charging in the Health Sector- Asset or Liability? 1995, Commonwealth Department of Human Services and Health: Sydney. p. 5-8.
36. Hellowell, M., Vecchi, V., An evaluation of the Projected returns to investors on 10 PFI projects commissioned by the NHS. . Financial Accountability and Management, , 2012. 28(1): p. 77-100.
37. Productivity Commission, Private and Public Hospitals Productivity Commission Discussion Draft 2009: Canberra. p. 261.
Sharing research about health facility design with industry colleagues was one of the main reasons that the Australian Health Design Council (AHDC) was set up in 2012 by Editor Jane Carthey and colleagues. AHDC now has a well-established program of regular events for our members sharing health design innovations, evidence and experience. So it’s now time for us to go further in delivering value to our members. We invite you to view this blog regularly, and to contribute your experience and expertise wherever and whenever you can. This is a new and exciting journey for the AHDC and we invite you to join us on it.
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.
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 operational energy/carbon consumed during the life of the building;
the embodied energy/carbon consumed during the production of the materials from which the building is constructed;
the energy/carbon used in the construction process itself;
maintenance and replacement; and,
The demolition and recycling of its elements at its end of life.
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.
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.
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