Hospital

OVERVIEW
"A functional design can promote skill, economy, conveniences, and comforts; a non-functional design can impede
activities of all types, detract from quality of care, and raise costs to intolerable levels." ... Hardy and Lammers
Hospitals are the most complex of building types. Each hospital is comprised of a wide range of services
and functional units. These include diagnostic and treatment functions, such as clinicallaboratories, imaging,
emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental
inpatient care or bed-related function. This diversity is reflected in the breadth and specificity of regulations, codes,
and oversight that govern hospital construction and operations. Each of the wide-ranging and constantly evolving
functions of a hospital, including highly complicated mechanical, electrical, and telecommunications systems, requires
specialized knowledge and expertise. No one person can reasonably have complete knowledge, which is why
specialized consultants play an important role in hospital planning and design. The functional units within the hospital
can have competing needs and priorities. Idealized scenarios and strongly-held individual preferences must be
balanced against mandatory requirements, actual functional needs (internal traffic and relationship to other
departments), and the financial status of the organization.

VAMC Bay Pines, FL
In addition to the wide range of services that must be accommodated, hospitals must serve and support many
different users and stakeholders. Ideally, the design process incorporates direct input from the owner and from key
hospital staff early on in the process. The designer also has to be an advocate for the patients, visitors, support staff,
volunteers, and suppliers who do not generally have direct input into the design. Good hospital
design integrates functional requirements with the human needs of its varied users.
The basic form of a hospital is, ideally, based on its functions:
bed-related inpatient functions
outpatient-related functions
diagnostic and treatment functions
administrative functions
service functions (food, supply)
research and teaching functions
Physical relationships between these functions determine the configuration of the hospital. Certain relationships
between the various functions are requiredas in the following flow diagrams.


These flow diagrams show the movement and communication of people, materials, and waste. Thus the physical
configuration of a hospital and its transportation and logistic systems are inextricably intertwined. The transportation
systems are influenced by the building configuration, and the configuration is heavily dependent on the transportation
systems. The hospital configuration is also influenced by site restraints and opportunities, climate, surrounding
facilities, budget, and available technology. New alternatives are generated by new medical needs and new
technology.
In a large hospital, the form of the typical nursing unit, since it may be repeated many times, is a principal element of
the overall configuration. Nursing units today tend to be more compact shapes than the elongated rectangles of the
past. Compact rectangles, modified triangles, or even circles have been used in an attempt to shorten the distance
between the nurse station and the patient's bed. The chosen solution is heavily dependent on program issues such
as organization of the nursing program, number of beds to a nursing unit, and number of beds to a patient room. (The
trend, recently reinforced by HIPAA, is to all private rooms.)
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BUILDING ATTRIBUTES
Regardless of their location, size, or budget, all hospitals should have certain common attributes.
Efficiency and Cost-Effectiveness
An efficient hospital layout should:
Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces
Allow easy visual supervision of patients by limited staff
Include all needed spaces, but no redundant ones. This requires careful pre-designprogramming.
Provide an efficient logistics system, which might include elevators, pneumatic tubes, box conveyors, manual or automated carts,
and gravity or pneumatic chutes, for the efficient handling of food and clean supplies and the removal of waste, recyclables, and
soiled material
Make efficient use of space by locating support spaces so that they may be shared by adjacent functional areas, and by making
prudent use of multi-purpose spaces
Consolidate outpatient functions for more efficient operationon first floor, if possiblefor direct access by outpatients
Group or combine functional areas with similar system requirements
Provide optimal functional adjacencies, such as locating the surgical intensive care unit adjacent to the operating suite. These
adjacencies should be based on a detailed functional program which describes the hospital's intended operations from the
standpoint of patients, staff, and supplies.

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Flexibility and Expandability
Since medical needs and modes of treatment will continue to change, hospitals should:
Follow modular concepts of space planning and layout
Use generic room sizes and plans as much as possible, rather than highly specific ones
Be served by modular, easily accessed, and easily modified mechanical and electrical systems
Where size and program allow, be designed on a modular system basis, such as the VA Hospital Building System. This system
also uses walk-through interstitial space between occupied floors for mechanical, electrical, and plumbing distribution. For large
projects, this provides continuing adaptability to changing programs and needs, with no first-cost premium, if properly planned,
designed, and bid. The VA Hospital Building System also allows vertical expansion without disruptions to floors below.
Be open-ended, with well planned directions for future expansion; for instance positioning "soft spaces" such as administrative
departments, adjacent to "hard spaces" such as clinical laboratories.
Therapeutic Environment

Hospital patients are often fearful and confused and these feelings may impede recovery. Every effort should be
made to make the hospital stay as unthreatening, comfortable, and stress-free as possible. The interior designer plays
a major role in this effort to create a therapeutic environment. A hospital's interior design should be based on a
comprehensive understanding of the facility's mission and its patient profile. The characteristics of the patient profile
will determine the degree to which the interior design should address aging, loss of visual acuity, other physical and
mental disabilities, and abusiveness. (See VA Interior Design Manual.) Some important aspects of creating a
therapeutic interior are:
Using familiar and culturally relevant materials wherever consistent with sanitation and other functional needs
Using cheerful and varied colors and textures, keeping in mind that some colors are inappropriate and can interfere with provider
assessments of patients' pallor and skin tones, disorient older or impaired patients, or agitate patients and staff, particularly some
psychiatric patients .
Admitting ample natural light wherever feasible and using color-corrected lighting in interior spaces which closely approximates
natural daylight
Providing views of the outdoors from every patient bed, and elsewhere wherever possible; photo murals of nature scenes are
helpful where outdoor views are not available
Designing a "way-finding" process into every project. Patients, visitors, and staff all need to know where they are, what their
destination is, and how to get there and return. A patient's sense of competence is encouraged by making spaces easy to find,
identify, and use without asking for help. Building elements, color, texture, and pattern should all give cues, as well as artwork
and signage. (As an example, see VA Signage Design Guide.)
For an in-depth view see WBDGTherapeutic Environments.

Cross-section showing interstitial space with deck above an occupied floor
Cleanliness and Sanitation
Hospitals must be easy to clean and maintain. This is facilitated by:
Appropriate, durable finishes for each functional space
Careful detailing of such features as doorframes, casework, and finish transitions to avoid dirt-catching and hard-to-clean
crevices and joints
Adequate and appropriately located housekeeping spaces
Special materials, finishes, and details for spaces which are to be kept sterile, such as integral cove base. The new antimicrobial
surfaces might be considered for appropriate locations.
Incorporating O&M practices that stress indoor environmental quality (IEQ)
Accessibility
All areas, both inside and out, should:
Comply with the minimum requirements of the Americans with Disability Act (ADA) and, if federally funded or owned,
the GSA's ABA Accessibility Standards
In addition to meeting minimum requirements of ADA and/or GSA's ABA Accessibility Standards, be designed so as to be easy
to use by the many patients with temporary or permanent handicaps
Ensuring grades are flat enough to allow easy movement and sidewalks and corridors are wide enough for two wheelchairs to
pass easily
Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to dark and light; marking glass walls
and doors to make their presence obvious
Controlled Circulation
A hospital is a complex system of interrelated functions requiring constant movement of people and goods. Much of
this circulation should be controlled.
Outpatients visiting diagnostic and treatment areas should not travel through inpatient functional areas nor encounter severely ill
inpatients
Typical outpatient routes should be simple and clearly defined
Visitors should have a simple and direct route to each patient nursing unit without penetrating other functional areas
Separate patients and visitors from industrial/logistical areas or floors
Outflow of trash, recyclables, and soiled materials should be separated from movement of food and clean supplies, and both
should be separated from routes of patients and visitors
Transfer of cadavers to and from the morgue should be out of the sight of patients and visitors
Dedicated service elevators for deliveries, food and building maintenance services
Aesthetics
Aesthetics is closely related to creating a therapeutic environment (homelike, attractive.) It is important in enhancing
the hospital's public image and is thus an important marketing tool. A better environment also contributes to better
staff morale and patient care. Aesthetic considerations include:
Increased use of natural light, natural materials, and textures
Use of artwork
Attention to proportions, color, scale, and detail
Bright, open, generously-scaled public spaces
Homelike and intimate scale in patient rooms, day rooms, consultation rooms, and offices
Compatibility of exterior design with its physical surroundings
Security and Safety
In addition to the general safety concerns of all buildings, hospitals have several particular security concerns:
Protection of hospital property and assets, including drugs
Protection of patients, including incapacitated patients, and staff
Safe control of violent or unstable patients
Vulnerability to damage from terrorism because of proximity to high-vulnerability targets, or because they may be highly visible
public buildings with an important role in the public health system.
Sustainability
Hospitals are large public buildings that have a significant impact on the environment and economy of the
surrounding community. They are heavy users of energy and water and produce large amounts of waste. Because
hospitals place such demands on community resources they are natural candidates for sustainable design.
Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy conservation standards
that meet EPAct 2005 (PDF 1.3 MB, 550 pgs) and Executive Order 13423requirements. The Energy Independence and Security
Act of 2007 (EISA) (PDF 740 KB, 310 pgs)provides additional requirements for energy conservation. Also see LEED's
(Leadership in Energy and Environmental Design) USGBC LEED for Healthcare
Related Issues
The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security and privacy of
"protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy, and may affect
location and layout of workstations that handle medical records and other patient information, paper and electronic,
as well as patient accommodations."
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EMERGING ISSUES
Among the many new developments and trends influencing hospital design are:
The decreasing numbers of general practitioners along with the increased use of emergency facilities for primary care
The increasing introduction of highly sophisticated diagnostic and treatment technology
Requirements to remain operational during and after disasterssee, for example, VA'sPhysical Security Manuals
State laws requiring earthquake resistance, both in designing new buildings and retrofitting existing structures
Preventative care versus sickness care; designing hospitals as all-inclusive "wellness centers"
Use of hand-held computers and portable diagnostic equipment to allow more mobile, decentralized patient care, and a general
shift to computerized patient information of all kinds. This might require computer alcoves and data ports in corridors outside
patient bedrooms. For more information, see WBDG Integrate Technological Tools
Need to balance increasing attention to building security with openness to patients and visitors
Emergence of palliative care as a specialty in many major medical centers
A growing interest in more holistic, patient-centered treatment and environments such as promoted by Planetree. This might
include providing mini-medical libraries and computer terminals so patients can research their conditions and treatments, and
locating kitchens and dining areas on inpatient units so family members can prepare food for patients and families to eat together.
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RELEVANT CODES AND STANDARDS
Hospitals are among the most regulated of all building types. Like other buildings, they must follow the local and/or
state general building codes. However, federal facilities on federal property generally need not comply with state and
local codes, but follow federal regulations. To be licensed by the state, design must comply with the individual state
licensing regulations. Many states adopt the FGI Guidelines for Design and Construction of Hospitals and Health Care
Facilities, listed below as a resource, and thus that volume often has regulatory status.
State and local building codes are based on the model International Building Code (IBC). Federal agencies are
usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and
Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's ABA Accessibility Standards takes precedence.
Since hospitals treat patients who are reimbursed under Medicare, they must also meet federal standards, and to be
accredited, they must meet standards of the Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO). Generally, the federal government and JCAHO refer to the National Fire Protection Association (NFPA)
model fire codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).
The American with Disabilities Act (ADA) applies to all public facilities and greatly the building design with its general
and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's
ABA Accessibility Standards apply to federal and federally funded facilities. The technical requirements do not differ
greatly from the ADA requirements. See WBDG Accessible
Regulations of the Occupational Safety and Health Administration (OSHA) also affect the design of hospitals,
particularly in laboratory areas.
Federal agencies that build and operate hospitals have developed detailed standards for the programming, design,
and construction of their facilities. Many of these standards are applicable to the design of non-governmental facilities
as well. Among them are:
Department of Veterans Affairs (VA), Office of Construction & Facilities Management Technical Information Library contains
many guides and standards, including:
o Design Guides for planning many different departments and clinics, design manuals of technical requirements, equipment lists,
master specifications, room finishes, space planning criteria, and standard details.
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MAJOR RESOURCES
WBDG
Federal Mandate
Executive Order 13423 Technical Guidance
Products and Systems
Building Envelope Design Guide
Websites
See WBDG Health Care Facilities for generic health care facilities websites
Publications
Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibrock and Debra
Harris. New York: John Wiley & Sons, Inc., 2011.Innovative design solutions in key areas such as lighting, acoustics, color,
and finishes
Design Guide for Improving Hospital Safety in Earthquakes, Floods, and High Winds: Providing Protection to People and
Buildings. FEMA, 2007.
Development StudyVA Hospital Building System by Building Systems Development and Stone, Marraccini & Patterson.
Washington, DC: U.S. Government Printing Office, rev. 1977.
Emergency Department Design: A Practical Guide to Planning for the Future by John Huddy and Michael T. Rapp. Irving,
Texas: ACEP (American College of Emergency Physicians) 2000.
Healthcare Facility Planning: Thinking Strategically by Cynthia Hayward, AIA, FAAHC, ACHA. Health Administration Press
and the American College of Healthcare Executives, 2005.
Hospitals, The Planning and Design Process, 2nd ed. by Owen B. Hardy and Lawrence P. Lammers. Rockville, Md.: Aspen
Publishers, 1996.
Hospital Interior Architecture: Creating Healing Environments for Special Patient Populationsby Jain Malkin. New York: John
Wiley & Sons, Inc., 1992.
Healthcare DesignA quarterly magazine with design articles and presentations of recent projects
Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition, by
Jain Malkin. New York: John Wiley & Sons, Inc., 2002.
Sound & Vibration: Design Guidelines for Health Care Facilities by the Acoustics Research Council. 2010.
UFC 4-510-01 Design: Medical Military Facilities
See WBDG Health Care Facilities for generic health care facilities publications
Tools
SpaceMedGuide-A Space Planning Guide for Healthcare Facilitiesa popular planning tool providing state-of-the-art planning
methodologies, industry benchmarks, and planning tips.