Status and Perspective of

Hospital Architecture in Japan

New Development of the University of Tokyo Teaching Hospital Project
Yasushi Nagasawa, Dr. Eng. Dip. HFP, JIA
Professor, Department of Architecture, Graduate School of
Engineering, The University of Tokyo
Vice-President, Healthcare Engineering Association of Japan

Office : Department of Architecture, Graduate School of

Engineering, The University of Tokyo,
7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan
Tel: +81-3-5841-6169, Fax: +81-3-5841-8516, e-mail :
tnagasy@mail.ecc.u-tokyo.ac.jp
Home : 4-1-3 Higashi Gotanda, Shinagawa-ku, Tokyo 141-0022 Japan
Tel: +81-3-3441-6057, Fax: +81-3-3441-6057, e-mail: donya@pop13.odn.ne.jp
BIOGRAPHY
Yasushi Nagasawa is Professor of the Department of Architecture at the University of Tokyo. He
has had a distinguished career as an eminent Japanese planner for hospitals and other healthcare
buildings in Japan and overseas, including consultation tasks with the World Health Organization.
He is the Council member of IFHE, Vice-President / International Committee Chairman of
Healthcare Engineering Association of Japan (HEAJ). He is designated as the Chairman of the 2002
Annual HEAJ Conference / Exhibition (Hospex Japan 2002). He is also Vice-President of MenEnvironment Research Association (MERA), Director-General of Global University Programs in
Healthcare Architecture (GUPHA) as well as a board member of Japan Institute of Healthcare
Architecture (JIHA) and Japanese Society of Hospital Administration (JSHA). From 1997 to 1999,
he was the Chairman of the Department of Architecture. From 1989 he had been an Associate
Professor at the University of Tokyo. In 1994 he was awarded an Architectural Institute of Japan
Prize in research and promoted to full professorship. From 1980 to 1988 he was a senior research
architect at the National Institute of Hospital Administration, Ministry of Health and Welfare,
where he was a research architect from 1974 to 1979. He began his architectural design career at
Yoshinobu Ashihara Architect and Associates, where he worked from 1968 to 1974. He holds a
Doctor of Engineering Degree from the University of Tokyo (1987) and post-graduate Diploma in
Health Facility Planning from the Council for National Academic Awards, UK (1978). He
graduated from the post-graduate course in Health Facility Planning at the Medical Architecture
Research Unit, Polytechnic of North London (1978). He became a qualified architect in Japan in
1972. He graduated from the Department of Architecture, Faculty of Engineering, The University of
Tokyo (1968) where he obtained a Bachelor of Engineering degree.

-1-

thursday may 16.

Status and Perspective of

Hospital Architecture in Japan
New Development of the University of Tokyo Teaching Hospital Project
WHAT IS THIS PRESENTATION ?
The objective of this presentation is to introduce briefly the evolution of heath facility design and
engineering in Japan on the basis of an overview of recent developments at the University of Tokyo
Teaching Hospital Project, which represents the state-of-the-art hospital architecture in Japan.
However, the emphasis here will focus on the perspective of year the 2000 and beyond, in current
design trends in health facility planning and design, and precedents trend in this specialized field
through out the 20th century.

IN WHAT WAY WERE JAPANESE HOSPITAL BUILDINGS DEVELOPED ?

Chinese culture, principally Buddhism, exerted an overwhelming influence upon Japanese culture
from the earliest days. Religion, as well as medical care, was based on Chinese medical technology,
e.g. herbal medicine, acupuncture, massage. Buddhism temples provided treatment and
accommodation for the poor and the sick. Christianity was introduced by Spanish missionaries and
the first Western style hospital was built in the 16th century by Portuguese missionaries, however,
this tradition ceased by the 17th century. This occurred because Christianity was banned as Japan
closed its doors to overseas countries during the Edo period for over 250 years until the mid-19th
century. In the mid-17th century, Dutch medicine was introduced in the Nagasaki Concession, this
being the single area permitting communication with the outside world during the Edo period.
Dutch influence continued until the Meiji Restoration in the 19th century (1968) when the Meiji
government decided to follow the model of German medicine for medical education.
The University of Tokyo Teaching Hospital (UTH) was established at its present site in 1876 as the
first teaching hospital in Japan and has been the site of excellent medical research and teaching
advancements since that time. The architectural development of UTH is significant because it has
reflected various nationwide influences to incorporate various innovations in medical and building
technologies at each stage of the institutions development.
The first stage of UTH building in the 19th century was a pavilion-type wood structure. In the early
part of the 20th century, hospital buildings in elsewhere in Japan were orientated to emulate the
medical teaching hospitals. Many pavilion type sanatoria were built as tuberculosis and other
infectious diseases spread throughout the country. From the beginning of the 20th century, UTH
buildings were renovated, representing the second major wave of construction activity. Western
style red roof tiles were in use during this period, although most of these structures were destroyed
in the Great Kanto Earthquake in 1924. As the third stage of construction activity corresponded
following the 1924 earthquake, Prof. Y. Uchida of the Department of Architecture was co-assigned
as Chief Architect of the University. He had an important role in creating an overall campus master
plan in the aftermath of the Earthquake. The hospital started the process of reconstructing its
facilities in the College Gothic style with steel-reinforced concrete structures in order to resist future
earth tremors. The symmetrical layout plan of the hospital was drawn according to German
planning concepts, i.e. the core Medical block on the left and core Surgical block on the right. The
out-patient department (OPD) block was located in front and administration block, which was
located on the other side of court yard from the OPD block. Actually only the OPD was completed
in 1934, and the medical block was constructed just before 1945.

-2-

thursday may 16.

American concepts of effective hospital administration were introduced following World War II
and new medical laws were legislated. The National Institute of Hospital Administration, now
called NIHSM, was established under the Ministry of Health and Welfare in order to train hospital
directors (Japanese trained-physicians) and other (nursing/business) directors in contemporary
principles of information management, modern hospital care and contemporary frontiers of health
facility planning and management. This oversight also extended to the design of the numerous new
facilities which were needed in the post-war years. Based on the concept of centralization of
diagnosis/therapeutic and servicing/logistic functions, a model plan for a 180-bed general hospital
was developed in 1954 by Prof. Y. Yoshitake of the University. Since that time, research work on
the planning of hospital buildings and engineering, studies of healthcare buildings have been carried
out on or ongoing basis at the University of Tokyo, as well as at other universities and organizations
such as the Healthcare Engineering Association of Japan (HEAJ) and Japan Institute of Healthcare
Architecture (JIHA).
The period of 1952 to 1968 represented the forth stage of the development of the UTH campus.
Prof. Y. Yoshitake designed centralized the D/T department, e.g. operating theaters, radiology,
path-labs, as well as various supporting departments, e.g. catering, laundry and the CSSD, under
extremely tight budgets. In 1954, central operating theatres were completed as the first centralized
units of their type in Japan. In 1964, an 11 story tower- ward, one of the first double corridor
configurations in Japan was constructed on the campus.
The span of 1968 to 1982, characterized by 1960s-70s student struggles in the Universities, was a
period of only minor renovations in the physical plant, implemented without any consistent master
plan in effect. However, the earlier implementation of National Health Insurance System, in 1961,
encouraged the nation to provide on unprecedented number of hospital beds in order to cope with
the increasing demand for hospital care, in response to the post-war generation. Various hospital
owners in both the public and private sectors built and operated hospitals with relatively few serious
restrictions placed on them. The total number of hospitals and hospital beds in Japan are at present
9,500 and 1.7 million respectively (versus 1.4 million in the US) i.e. there is at present one hospital
bed per every 76 persons in Japan (versus one per every 171 persons in the US). However, this does
not mean Japanese hospital beds are accessible easily by patients since the length of inpatients' stay
in Japanese general hospitals is a little shorter than 30 days at the present time, far longer than in
other developed countries. Yet, tight capital investment budgets have resulted in shortages of floor
area in relation to the needs to accommodate many inpatients, out-patients, and a parade of new
high tech medical equipment and attendant procedures. In the course of the period of rapid
economic development, the situation of tight floor space gradually moderated, but is still below
comparable standards in other developed countries.
In 1982, a new master plan for the UTH, called System Master Plan, was developed. This master
plan has 4 phases, each aiming to firmly establish its place as a state-of-the-art center of excellence
within the family of teaching hospitals across Japan. The first phase was the D/T Department,
containing operating, path-lab and radiology and CSSD completed in 1987. The second phase was
the OPD, completed in 1993 with about 2700 patient visits per day. The third phase was an
inpatient tower, completed in 2000 with the first patient admitted in October of 2001.
This system master plan was originally developed by Prof. S. Suzuki of the University, in
association with Shinichi Okada Architect and Associates, with extensive support provided by the
Facility Department of the University and the Future Plan Promotion Unit of the UTH. Since 1989
the author has been the principal consultant to the project.
One of the characteristics of the UTH system master plan is the location of clear pedestrian mall,
hospital streets connecting each relevant department, which provides effective way finding for users
and maximum flexibility within a complex network of diagnostic and treatment domain areas.
-3-

thursday may 16.

Interstitial spaces (ISS) were introduced for ease of modifying the layout of rooms and to
accommodate highly sophisticated engineering support systems. All building system installations,
such as air conditioning, electric, automatic transportation and information wirings, are separate
from the building super structure, reflecting differences in the life spans of various building
technical support systems and sub-systems.
Typical floor layouts of the recently-built wards are considered to afford far better observation of
patients by staff, and significantly greater comfort levels for patients. Bed rooms mainly consist of
single bed rooms, some of which are used as semi-private rooms in order to accommodate the
requisite number of beds in the transition period until the final stage of the master plan is
completed. It is the first attempt in Japan to locate patients WC/Shower unit on the window side of
the room in order to enable maximum flexibility in the corridor side.
The fourth stage of UTH development will be the extension of D/T department followed by the
extension of wards. At the final stage of the master plans implementation, 1300 beds will be
equipped and available for service.

WHAT DO CURRENT JAPANESE HOSPIALS LOOK LIKE?

Although UTH is enjoying a very high standard of services of its buildings and engineering support
services, most other Japanese hospitals that been also experienced extensive expansions and
redevelopment during the 20th century. Each has its own merits and demerits in terms of its physical
plant and operational aspects. This typology of hospital can be described in terms of a set of
descriptive labels or nicknames. Eight of these are as follows:
1. Japanese hospitals which look like the Morning Market, where large numbers of
outpatients get together hours before receiving consultation. Despite this, better service is
not guaranteed by ones early arrival. This stems from an ineffective appointment system.
2. Japanese hospitals which look like the Rush-Hour Train, brimming with passengers all
packed tightly within a very limited floor area. Floor area per bed in Japanese general
hospitals is about 60 square meters, compared to more than 100 square meters in the USA
and Europe. This problem stems from the limitation of capital investment, and cost
limitations which necessitate the selection of small sites for the construction of hospitals.
3. Japanese hospitals which look like the Chowder Soup in a pot, which different types of
patients mixed in hospital wards, and also in situations where more than 50 patients are
routinely accommodated in one small nursing unit. These patients may be acute or longterm, children, or elderly people. This syndrome stems from lack of a designated role of
each hospital, symptomatic of a lack of regional networking as well as a chronic shortage of
nursing staff.
4. Japanese hospitals which look like Department Stores, rather than specialty shops. The
majority of hospitals provide medical services to all types of patients. From the hospital
administrative point of view, it is necessary to allocate all types of specialties in order to
cope with all patients needs. This also stems from a lack of regional planning and patients
lack of freedom of selection among multiple hospital choices for receiving care.
5. Japanese hospitals which look like the High-Tech Box, within artificial environments such
as air conditioning, mechanical ventilation and lighting, containing high-tech medical
equipment such as computer tomography (CT), magnetic resonance imaging (MRI),
automatic analyzers, material handling conveyors and various computer systems. This stems
from the fact that both Japanese patients and staff are fond of high-tech equipment without
their being concomitantly conscious of matters of cost-effectiveness.

-4-

thursday may 16.

6. Japanese hospitals which look like the Scrap and Build Shrines, similar to the ISE Shinto
Shrine, which has been renewed once every 20 years for thousands of years. This stems
from a national obsession with newer is better in Japan. When a hospital is standing for 10
years, it may be regarded as old by the Japanese. As a result Japanese hospitals tend to have
an unusually short life-span, and old facilities frequently suffer from poor maintenance.
7. Japanese hospitals which look like Slum Housing, dirty and crowded buildings with long
waiting times and an unfriendly, uninviting atmosphere. This frequently stems from poor
awareness of and often a disconcern disconcert for patients amenity and satisfaction in
terms of the care and management of the built-environment.
8. Japanese hospitals which look like the Clone Animals, arrayed from north to south
throughout the country. These hospitals are easily recognized from their exterior
appearance. Whether public or private, these buildings all look similar. This also stems from
the general attitude of the hospital administrators which operate these facilities. They want
to follow precedent alone and their neighbors idea above all else.
These eight distinctions help one to provide a general understanding of recent trends within Japan.

ON THE HOSPITAL OF THE FUTURE

Japanese hospitals have been characterized in the preceding discussion as being directly reflective
of myriad political, economical, social, technological and cultural factors. As a result, Japanese
hospital buildings themselves contain and express the following three physical features: Immense
and Independent, Compact Footprint and Tall, and Stand-alone and Uniform.
However, a key quality of life indicator, life expectancy at birth, is 77.2 years for males and 83.8
years for females in Japan, which at present is the longest in the world. The country enjoys high
quality in its health services with a relatively low cost of governmental expenditure. There are
several recent movements aimed at improving the current situation.
Regional healthcare planning law has been recently introduced, now requiring each local
government to work out a comprehensive health services provisional plan including the
demonstrate in of need through the submittal of a certificate of need report in relation to each new
hospital bed requested. A link between the hospital local clinics is requisite to meet this
requirement. Although each hospital is still principally independent, without affiliation in a larger
network, the case often remains where institutions house duplicative equipment including multiple
sets of diagnostic and treatment services in the future it is likely that hospital will regain to share
costly diagnostic equipment and services. Various off-site services have very recently become
widely available in Japan. Many hospital administrators are discussing, for the first time, the outsourcing of hospital services and the necessity of networking not only for diagnosis and treatment
but also for material purchasing, catering, sterilization and pharmaceutical operations, because past
redundancies in terms of specialties /services within the same region can not be supported nor
economically justified any longer.
Most people, however, still enjoy easy access to hospitals almost everywhere in Japan without
worrying about how much they have to pay due to the National Health Insurance program. Many
hospitals are now introducing an appointment system for the first time for out-patients
consultation. Now, especially in the case of tertiary hospitals, patients have to show a reference
letter from another clinic or hospital, otherwise they have to pay a certain amount in the form of a
registration fee.
The care of a growing number of elderly patients in general hospitals reveals the need to provide
various options, besides the hospital, for them to receive care, e.g. speciality geriatric hospitals,
halfway houses, skilled nursing homes, group homes and ordinary homes. Based on the rapid aging
-5-

thursday may 16.

of Japanese society, integration of institutional care with home-based care options is requisite. A
new care insurance system for the elderly was introduced in 2000. This system is redefining the
scope of care for the elderly. It has already begun to have a significant impact, although more
research is needed on this issue. As the result, it is hoped a shortening of the length of the typical
hospital inpatient stay will be achieved this is a critical factor for the attainment of more efficient
hospital management.
Recently, the revision of medical legislation enables hospitals to relate floor area to the level of
medical remuneration, i.e. an increase in floor space becomes an incentive for hospital
administrators to increase their monthly revenue. As many hospitals have begun to provide
environments specifically for acute and long-term patients, these patients will be able to self-select
the places which best suit the level of care one needs. In some of the most recently built hospitals,
the average floor area is 80-100 square meters per patient.
The disadvantages of compact and tall hospital buildings fully supported by air conditioning and
lighting were revealed in the aftermath of natural/man-made disasters and hazards such as
earthquakes, industrial explosions, and incidence of cross-infection, all highlighted in the mass
media in recent years. In addition, skyrocketing operational and maintenance cost have become
crucial issues to cope with. Discussions, often rather heated, are at present occurring with respect to
hospital building and engineering design principles in Japan. These debates crystallize the
continuing pressure to reduce operational cost rather than capital cost, and improvements in
progressive maintenance. These are the most frequently discussed themes. Life cycle cost, including
the demolition of antiquated buildings, is also a hotly contested issue.
The clear distinction of acute and chronic hospitals will reconfigure large nursing units into more
appropriate sizes dependent upon specific nursing requirements. High-tech medical technology will
be more rapidly and more sophisticatedly developed in the 21st century and applied to critical
care/life saving hospitals. In many developed countries, ambulant surgery is being given attention in
order to reduce the length of inpatient stays in hospitals. This trend might stem partly from financial
reasons. However, this technology will help Japanese patients to stay in their normal environment
as long as possible in the future. Naturally, patients do not wish to stay in the hospital for a long
time, if this is not necessary, in particularly in light of new treatment modalities.
On the other hand, more holistic and low-tech medical treatment will be also developed e.g.
terminal care in hospices or in their ones own home. Recent revisions to Japanese medical laws in
the past few years to support this new direction. The physical provision of improved caring
environments for patients, families, as well as of upgraded working environments for health care
staff is expected.
Architecture is an expression of culture. Local climate and customs are essential ingredients
which must continue to be taken into consideration when planning and building hospitals. Locallybased traditions in particular should be taken into serious consideration. Many such traditions have
proven to co-exist successfully with internationally recognized principles of modern medical
science.
As has been known since ancient times, the natural environment is a significant contributor to
recovery from illness. The modern hospital, with its artificial environment which ultimately
rendered the patient a little more than a machine cared for by the machines of the institution, lost
this timeless aspect of care. It is important to re-create true 'healing environments' in hospitals and
related health facilities. As hospital buildings and engineering technologies are regarded as the
hard dimensions of healing environments, it is essential to improve the soft dimensions of
healing environments, encompassing such attributes as a positive, cheerful staff, clean rooms, and
satisfying food. Without patient-centered philosophies, well-designed buildings and high-tech

-6-

thursday may 16.

equipment cannot create a truly therapeutic healing environment. In this regard, the role of the
Facility Manager in hospitals will grow in importance in the coming years in Japan and elsewhere.
Hospital Geography studies have been conducted by the author over the past numbers of years.
These studies stand our in terms shedding light on the experience of the viewpoint of each
individual person, including the patient, ones family and the staff. Finally, a new organization,
Global University Programs in Healthcare Architecture (GUPHA), founded as an international
organization in 2000, links and promotes education and research programs in health care
architecture internationally. This fledgling organization is currently undertaking studies on future
healthcare environments for the year 2050.

-7-

thursday may 16.

-8-

thursday may 16.

-9-

thursday may 16.