Sie sind auf Seite 1von 232

The Practice of Integrated Design:

The Case Study of Khoo Teck Puat Hospital, Singapore

Tan Shao Yen

31 st January 2012

A dissertation submitted in partial fulfillment of the regulations for the Degree of Masters of Science in Sustainable Building Design in BCA Academy - University of Nottingham, 2012.

Acknowledgements

I would like to thank my supervisor, Dr Peter Rutherford, for the inspiration, recommendation and continuous personal guidance. The gratitude is also extended to all the lecturers and tutors from Department of Architecture and Built Environment, for their dedication despite the geographical, temporal and scheduling challenges between the United Kingdom and Singapore.

Special thanks go to the BCA Academy and their staff who made the course possible in the first place. Immense efforts had been put in by them into the logistics and coordination that had gone into balancing the needs of the academic programme and the part-time working students, given their diverse background and career demands.

Sincere thanks to the exemplary Khoo Teck Puat Hospital, especially Mr Donald Wai Wing Tai, for granting visits to and information regarding the Hospital, allowing invaluable insights into the subject matter discussed in this dissertation.

I am indebted to my company, CPG Consultants Pte Ltd, for the support I have received from and the inconveniences my colleagues have put up with, in order for me to pursue the course. Special thanks to Mr Pang Toh Kang, Mr Khew Sin Khoon, Mr Lye Kuan Loy, Mr Kok King Min for their understanding and support. I would like also to thank Dr Lee Siew Eang, Mr Glenn Bontigao, Mr Lee Soo Khoong, Mr Lim Lip Chuan, Mr Jerry Ong, Ms Pauline Tan, Mr Toh Yong Hua, Mr Ng Kim Leong, Mr Soon Chern Yee, Ms Wong Lee Phing, Mr Yeo Tiong Yeow, Dr Nirmal Kishnani, and Mr Sng Poh Liang for sharing insights, experience and information regarding the Khoo Teck Puat Hospital project.

Words cannot express the love, support and sacrifice I have received from my family, without which it is hard to imagine how I would be able to juggle work, study and family; a big thank you to you all.

1

Abstract

Contemporary challenges have necessitated the application of sustainable principles and practices to the building construction industry. In order to do so, integrated design processes and practices have come to the fore as an important aspect in the delivery of sustainable buildings. In recent years, sustainable building projects that purport to be based on integrated design have emerged and appear to be gathering momentum in different parts of the world, including Singapore. Such an integrated approach is backed extensively in the literature, and as such numerous questions have been raised with respect to integrated design in practice. These include what is a sustainable design brief; how do the various stakeholders play out their roles in the integrated design process; what are the challenges and mindset changes required by the stakeholders in a building project to ensure the successful realization of integrated design?

Completed in 2010, the Khoo Teck Puat Hospital in Singapore provided an interesting case study to study the integrated design process in action. As stated in its design brief, it aims to be a healthcare building for the future through, first, achieving a “visually pleasing design that sustain with time” (Alexandra Hospital, 2005 1 ); and second, the “ease and low cost of maintainability resulting from careful overall design and material selection.” (Ibid.) The outcome of the design necessitated close collaboration between its many stakeholders through an integrated manner. The aim of this dissertation is therefore to first, examine how the design of Khoo Teck Puat Hospital has embraced certain principles of sustainability; second, how elements of the integrated design process have successfully contributed to such design outcomes, as well as practical challenges faced in the integrated design process. This dissertation concludes by making recommendations that aim to overcome the practical challenges, thereby facilitating the integrated design process, and hence improving the quality of sustainable building design.

Keywords: Sustainable building design, Integrated design, Sustainable Healthcare Architecture.

1 Tender briefing materials by Alexandra Hospital, the forerunner of Khoo Teck Puat Hospital.

2

Declaration

I understand the nature of plagiarism and I am aware of the University’s policy on this. I certify that this dissertation reports original work by me and that all the sources I have used or quoted have been indicated by means of completed references.

Signature

3

31 January 2012 Date

Table of Contents

Acknowledgements

1

Abstract

2

Declaration

3

Table of Contents

4

List of Tables

9

List of Figures

10

Chapter 1.0: Introduction

13

1.1 Background and Context of Healthcare Architecture

14

1.2 Scope and Objectives

16

1.3 Research Questions

17

1.4 Dissertation Structure

17

1.5 The Key Challenges of Healthcare Architecture in Singapore

19

1.5.1 Challenges Related to the Provision of Medical Services

19

1.5.2 Challenges Related to Healthcare Organization, Structure and Culture

20

1.6

Sustainable Healthcare Architecture in Singapore’s Context

21

1.6.1 Economic Sustainability

22

1.6.2 Social Sustainability

24

1.6.2.1 The Relationship between Human Wellness and Environment

24

1.6.2.2 Sustaining Community through Healthy Public Place

26

1.6.3 Environmental Sustainability

26

1.6.4 Defining Sustainable Healthcare Architecture

30

1.7

Discussion: The Need to Integrate Inter-Disciplinary Knowledge

31

Chapter 2.0: The Integrated Design Approach

33

2.1

The Definition of Integrated Design Approach

34

4

2.2

Benefits of the Integrated Design Approach in Healthcare Architecture

35

2.2.1 Increasing Scale & Complexity

36

2.2.2 Failure of Traditional Siloed and Linear Design Process

36

2.2.3 The Integrated Design Process

37

2.2.4 Achieving Sustainable Healthcare Architecture

38

2.2.5 Learning Organization

39

2.3

Essential Elements of the Integrated Design Approach for Healthcare Architecture

39

2.3.1 The Multi-Disciplinary Project Team

40

2.3.2 Mind Set Change: The Need for a Whole-System Mental Model

42

2.3.3 Integrated Design Process

44

2.3.3.1 Team Formation and Organization

46

2.3.3.2 Visioning

49

2.3.3.3 Objectives Setting

49

2.3.3.4 Design Iteration

50

2.3.3.5 Construction & Commissioning

53

2.3.3.6 Post Occupancy Feedback Loops

54

2.3.3.7 Comparison Between IDP and Linear Design Process

54

2.3.4

Tools and Techniques that Support Integrated Design

55

2.3.4.1 Integrated

Design Tools

55

2.3.4.2 Integrated Design Techniques

59

2.3.5

Integrated Design Products: Sustainable Healthcare Architecture

60

2.4

Discussion: The Aspects of Integrated Design Process to be Investigated

62

Chapter 3.0: Khoo Teck Puat Hospotal: The Case Study

63

3.1 Background

64

3.2 KTPH’s Site Context

64

3.3 KTPH Visioning, Objective Setting and Briefing Process

68

3.3.1

Methodologies: Focused Group Discussions and References

68

5

3.3.2

The Shared Visions

69

3.3.2

Setting the Objectives

71

3.4

KTPH Team Formation and Organization

75

3.4.1 The role of IDP Facilitator

76

3.4.2 The role of the Architect + IDP Facilitator for Building Design

77

3.4.3 The role of the Hospital Planning Team + IDP Facilitator for User Groups

78

3.4.4 The role of the Prime Consultant Team

79

3.4.5 The role of the Green Consultant

80

3.4.6 The role of User Groups

80

3.4.7 The role of the Contractor

81

3.5

Discussion: KTPH’s Visioning, Objective Setting and Team Formation

81

Chapter 4.0: KTPH’s Integrated Design Process

83

4.1

The Process Map

84

4.1.1 DC: Design Competition (Prelim)

85

4.1.2 W1: Visioning Workshop

87

4.1.3 W2: Masterplanning Workshop

87

4.1.4 MP: Schematic Design Research/Analysis/Design Process

87

4.1.5 SD: Schematic Design

88

4.1.6 VE1: Value Engineering Workshop

88

4.1.7 DD1 & DD2: Design Development

89

4.1.8 VE2: Value Engineering Workshop

90

4.1.9 The Practice of Workshop/Design Charrette

90

4.1.10 Hospital Planning Committee Meetings that were held monthly

91

4.2

The Iterative Process

92

4.2.1 Schematic Design (SD) Stage

93

4.2.2 The Design Development (DD1) Stage

99

4.2.3 The Component Design (DD2) Stage

107

6

4.2.3.1

Wind Wall at the Naturally Ventilated Subsized Ward Tower

108

4.2.3.2 Detailed Deisgn of Spot Cooling at Roof Terraces: New Air

110

4.2.3.3 Water Efficient Landscaping Irrigation System

114

4.2.3.4 Resource-Efficient M&E System Design

115

4.3

Discussion: KTPH’s Integrated Design and Iterative Process

116

Chapter 5.0: Conclusion

118

5.1

KTPH: Sustainable Healthcare Architecture in Singapore

119

5.1.1 KTPH as a Green Building

119

5.1.2 KTPH: Embracing Social Sustainability

121

5.1.3 KTPH: Embracing Environmental Sustainability

121

5.1.4 KTPH: Mapping the Attributes of Sustainable Healthcare Architecture and Integrated

 

Design Approach

122

5.2

Lessons Learnt on the Practice of Integrated Design from the KTPH Case Study

124

5.2.1 The KTPH Briefing Process

124

5.2.2 Entrenched Practice among Building Professionals

125

5.2.3 Issues Related to Mindset Change

126

5.2.4 Lack of Integrated Design Process Toolkit

126

5.2.5 Fragmentary Design and Documentation Platform

126

5.2.6 Issues Related to Contractor Appointed via Conventional Approach

127

5.3 Discussion: the Practice of Integrated Design

127

5.4 Recommendations

129

Appendix I: Roles of Team Members By Design Phases

131

Appendix II: Iterative Process in Integrated Design

136

Appendix III: Building Information Modelling

157

Appendix IV: Design Consortium of the KTPH Project

164

Appendix V: Interview Guide

166

7

Appendix VI: Evidence-Based Design Principles

173

Appendix VII: Energy-Efficient Active Design Measures

180

Appendix VIII: Water-Efficient Considerations

183

Appendix IX: Indoor Environmental Quality

185

Appendix X: Renewable Energy Systems & Other Innovation Measures

188

Appendix XI: Integrated Design during Construction Phase

192

Appendix XII: KTPH’s BCA Green Mark Performance

195

Appendix XIII: Thermal Comfort Outcome of KTPH’s Bioclimatic and Natural Ventilation

Strategies

199

Appendix XIV: Evaluating Human Wellness and Social Sustainability of KTPH

204

Appendix XV: KTPH’s Environmental Stewardship

209

Bibliography

217

Word Count: 19,023

8

List of Tables

Table 1.1

Table 1.2

Table 1.3

Table 1.4

Table 2.1

Table 2.2

Table 2.3

Table 2.4

Table 2.5

Table 2.6

Table 2.6

Table 3.1

Table 3.2

Table 3.3

Table 3.4

Table 3.5

Table 4.1

Table 4.2

Table 4.3

Table 4.4

Table 4.5

Table 4.6

Table 4.7

Table 5.1

Table 5.2

Table 5.3

Table 5.4

Challenges related to provision of medical services

Challenges Related to Healthcare Organization, Structure and Culture

Evidence-based design relevant to built environment

Sustainable design guides and green rating tools for healthcare facilities

General factors contributing to current fragmentary state of design practice

Comparison between Integrated and Conventional Design Processes

Positive attitudes necessary among the integrated design team members

WSIP Process Stages (2007, p.8)

Core Integrated Project Team Member

Additional Integrated Project Team Members

IDP: Research and workshop activities for healthcare architecture

Key project team members involved in focus group discussions

AH/KTPH Shared values

Organizing performance criteria for evaluating the integration of systems

Framing the sustainability focuses in KTPH’s brief for design competition

AH/KTPH user work groups / departments

Integrated Design Activities

Integrated design considerations for façade, thermal comfort and energy usage

Integrated design activities for the envelope design

Integrated system design and system efficiency within systems

Evidence-based evaluation for ‘New Air’ (spot cooling at outdoor roof terrace)

Comparison between WSIP Process Elements (2007) and KTPH Design Process

Mapping KTPH’s integrated design process against the IDP model with reference to Figure 4.1 and 4.2

Key Building Performance Characteristics

Sustainability attributes of KTPH

Integrated design attributes of KTPH

Areas of study proposed for sustainability performance of KTPH

9

List of Figures

Figure 1.1

Figure 1.2

Figure 1.3

Figure 1.4

Figure 1.5

Figure 1.6

Figure 2.1

Figure 2.2

Figure 2.3

Figure 2.4

Figure 2.5

Figure 2.6

Figure 2.7

Figure 2.8

Figure 2.9

Figure 2.10

Figure 2.11

Figure 2.12

Figure 2.13

Figure 2.14

Figure 3.1

Figure 3.2

Figure 3.3

Figure 3.4

Figure 3.5

Figure 4.1

The complex relationships between the hospital functions

The typical compartmentalized, episodic model of care

Khoo Teck Puat Hospital’s holistic ‘Head-To-Toe Lifelong Anticipatory Healthcare of Whole Person’ model

Comparisons of some green rating systems for sustainable buildings

Trajectory of environmentally responsive design

Model of sustainable healthcare architecture

Multi-disciplinary project team for healthcare project

Bryan Lawson’s model of design problems or constraints

The new mental model for integrative design

Zeisel’s user-needs gap model

Conventional design team organization

Integrated design Team organization

Triple Bottom Line approach goal setting for a project visioning session

Integrative design process

Iterative process as proposed in ‘Strategies for integrative building design

‘Iteration loops’ as proposed in ‘Strategies for integrative building design

Integrative design process versus linear design process

The integrated design model

The traditional team model and an integrated design team model in information exchange

Achieving sustainable healthcare architecture through integrated design

KTPH layout with reference to its site context

Garden in a Hospital: Courtyard view of Khoo Teck Puat Hospital with naturalistic, lush greenery

Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond

Integration of healthcare, social, and natural environments

KTPH’s integrated design team organization

Integrated design process in KTPH

10

List of Figures (Cont’d)

Figure 4.2

Figure 4.3

Figure 4.4

Figure 4.5

Figure 4.6

Figure 4.7

Figure 4.8

Figure 4.9

Figure 4.10

Figure 4.11

Figure 4.12

Figure 4.13

Figure 4.14

Figure 4.15

Figure 4.16

Figure 4.17

Figure 4.18

Figure 4.19

Figure 4.20

Figure 4.21

Figure 4.22

Figure 4.23

The theoretical model of integrative design process

Integrated design team organization at the design competition stage

KTPH iterative process basing on the model building design

in ‘Strategies for integrative

Iterative process model during the schematic design phase

Landscape plan showing landscaped courtyard as the heart and lung of design

Landscape schematic drawing

Sketch design for landscaped roof terrace as social space, while providing good shading and insulation to interior spaces below

Landscaped oof terrace at Level 4 where patients, visitors, staff may enjoy moments of solitude or share moments of comfort or grieve; it is also a source of visual relief from the wards

Landscaped roof terrace at Level 5 overlooking Level 4

Iterative process model during the schematic design phase

Bioclimatic response of KTPH: sunpath

Bioclimatic response of KTPH: prevalent wind directions

Aspect ratio of the various block

Critical review based on ‘Environmental Design Guide for Naturally Ventilated and Daylit Offices’

Design study 1 for façade shading of the naturally ventilated ward tower

Design study 2 for façade shading of the naturally ventilated ward tower

Design study 3 for façade shading of the naturally ventilated ward tower

Design developed from Option 3: Fully height louvred façade and light shelf maximizes natural ventilation and daylight

Design developed from Option 3: Effect of rain needs to be considered in the tropics. These diagrammes indicate integration of monsoon windows providing ventilation during rain, even when the louvred windows are closed

Interior of naturally ventilated ward: Façade system comprising louvred wall, light shelves, and monsoon window. Natural ventilation is supplemented with individually controlled fans

Iterative process model during the late design development (DD2) phase

Sampling points measured in wind tunnel study

11

List of Figures (Cont’d)

Figure 4.24

Figure 4.25

Figure 4.26

Figure 4.27

Figure 4.28

Figure 4.29

Figure 4.30

Figure 4.31

Figure 4.32

Figure 4.33

Figure 4.34

Figure 5.1

Figure 5.2

Figure 5.3

A sample of the air velocity profile across a typical ward at 1.2m height @ open,

50% open and closed conditions

A sample of the pressure coefficients chart across the façade of the subsidised

ward tower obtained as boundary conditions for the CFD study

1:20 Wind tunnel model used for the study

Subsidized ward tower façade showing solar screen to provide shade and wind wall to induce air movement. Greenery is also integrated into the façade to enhance visual relief

Design drawing showing location of exhaust nozzle integrated into the façade, and the direction of throw to cool the landscaped roof terraces

CFD Simulation showing approximately 2°C reduction in temperature at the roof terrace, delivering cooling sensation to users

CFD simulation showing the throw of exhaust nozzle, and the wind speed gradient. A 2m/s wind speed is achieved at the end of the throw

Noise level (dBA) at various distances (m) from the nozzle diffuser. The noise level at landscaped roof terrace at 5m away from nozzle diffuser is 43dBA, which is equivalent to outdoor ambient sound level

Selection of component: Oscillating nozzle diffusers tested to ISO 5135 1997 and ISO 3741 1999 on sound power level performance to allow for better throw

distribution

Conceptual diagramme of irrigation system and built environment as part of natural systems

Schematic of irrigation system, drawing water from Yishun

KTPH: Post Occupancy Studies

KTPH:

Architecture Model

Sustainable

Attributes

mapped

onto

the

Sustainable

Healthcare

KTPH Integrated design process: questions framed with the IDP Mental Model

12

“Some people prefer to think of health as the absence of disease, while others insist that health is a state of physical, mental, and social well being.”

Ted Schettler “With twenty-first-century businesses increasing emphasis on triple-bottom-line imperatives – not
Ted Schettler
“With twenty-first-century businesses
increasing emphasis on triple-bottom-line
imperatives – not only for competitive
advantage but also for planetary survival –
healthcare’s singular blend of
environmental, economic and social agendas
is a model worthy of replication by other
sectors.”
Robin Guenther and Gail Vittori
Chapter 1.0: Introduction

13

Chapter 1.0

Introduction

1.1 Background and Context of Healthcare Architecture

Healthcare architecture consists of a wide range of building types, ranging from small neighbourhood clinics to large hospital complexes; from the general hospitals providing a comprehensive range of medical services to the specialized hospitals that focus on a selected field of medical services and/or research. Large-scale hospitals are arguably one of the most complex building types, having to accommodate a wide range of functions and services, for example, outpatient facilities, diagnostic and treatment facilities, accident and emergency facilities, operating theatres, clinical laboratories, radiography and imaging facilities, administration, food services and housekeeping, etc. The diverse range of functions and specialized needs require the support of sophisticated and advanced systems, for example, life support, telecommunication, space comfort and hygiene, as well as building services that have to be robustly designed (Carr, 2011).

services that have to be robustly designed (Carr, 2011). Figure 1.1 The complex relationships between the
services that have to be robustly designed (Carr, 2011). Figure 1.1 The complex relationships between the

Figure 1.1 The complex relationships between the hospital functions. Source: Carr, R. F. Hospital’ in Whole Building Design Guide. Internet WWW: http://www.wbdg.org/design/hospital.php

The complex physical functions of large healthcare facilities are to be considered in relation to the network of stakeholders that are involved with large scale hospitals,

14

including patients, doctors, nursing staff, administration staff, servicing staff, visitors, social and volunteer workers, maintenance crew, suppliers, etc. Conflicting demands arising out of the myriad of needs and requirements are only to be expected. Good healthcare design not only seeks to resolve these conflicts, but provide an integrated solution that addresses the following (Ibid.):

1. Efficient operation and cost effectiveness

2. Flexibility and expandability

3. Therapeutic environments

4. Cleanliness and sanitation

5. Accessibility

6. Controlled circulation

7. Aesthetic

8. Security and safety

9. Sustainability

Large-scale healthcare facilities also consume significant resources. To begin with, they are costly to build; hence significant financial resources are committed to building them, be it funded by the taxpayer, by private means or both, such as via public-private partnership (PPP) or private finance initiative (PFI). After they are built, not only are healthcare buildings significant consumers of energy 2 and water, they are also producers of significant quantities of clinical waste, on a round-the-clock, day-to-day basis. The ultimate goals of healthcare facilities, however, must surely be in meeting social objectives and human wellness; not only for patients who seek treatment, but also the community working in the healthcare built environments (Carr, 2011, 2011; Ray, D, Betterbricks, Mason, 2006). With the rising global demand for both good quality and affordable healthcare (World Health Report, 2008), a compelling case must surely be put forth for all healthcare buildings to be designed and operated in a sustainable manner economically, environmentally, and socially (Ibid.).

2 The US Commercial Building Energy Consumption Survey conducted in 2003 found that hospital used an average of 250,000 BTU/ft 2 (approximately 788.6kW/m 2 ), second only to food service buildings (Singer, B. C., 2009).

15

1.2

Scope and Objectives

Through a case study of a hospital project in Singapore that was completed in 2010, this dissertation examines how the integrated design approach had, in practice, contributed to social and environmental sustainability in healthcare architecture. This is done by first studying and understanding the issues related to sustainable healthcare architecture, and how integrated design can play an important role in realizing sustainable healthcare architecture, given that it necessitates the involvement of a network of stakeholders with specialized knowledge. Second, the dissertation shall study the integrated design approach in theory, so as to identify the key elements relevant for healthcare architecture. Next, the findings shall be compared with what had taken place in practice through examining the case study of a recently completed hospital in Singapore, namely the Khoo Teck Puat Hospital (KTPH). Based on the comparative analysis and lessons learnt, this dissertation concludes with recommendations on how the practice of integrated design may be further researched and improved.

The objectives of this dissertation are hence as follows:

1. Explore some recent developments and understanding of sustainable healthcare architecture, and its relationship with integrated design.

2. Identify, as far as possible, the essential elements that comprise the integrated design approach in the context of healthcare architecture, by drawing upon and making comparison from literature references.

3. Through documentation study of the KTPH project and interviews with its project team members, understand how the visioning and briefing process; formation and organization of integrated project team; the integrated design process and the design iterations of KTPH took place, to critically appraise the integrated design process in practice.

4. Analyze comprehensively the extent of integrated design process played out in the KTPH project, the lessons learnt by its team members, and how such lessons could contribute to future application of integrated design process in practice.

16

1.3

Research Questions

Through these objectives, this research will investigate the benefits associated with the integrated design process in realizing sustainable healthcare architecture. In so doing, four main research questions are posed, namely:

1. How do we define sustainable healthcare architecture in the Singapore context?

2. What are the salient elements of the integrated design approach and how are they relevant for sustainable healthcare architecture?

3. How is integrated design carried out in the practice of healthcare architectural design?

4. What are the lessons learnt in the integrated design process in the practice of healthcare architecture?

5. How can the lessons learnt benefit future practice of integrated design in healthcare architecture?

6. The research methodology includes literature review based on publicly accessible information, access to document archived within the organizations involved in the KTPH project, and interview with design/project team members involved in KTPH project. Materials used in this dissertation are limited to information that had been permitted for publication by the sources of the information.

1.4 Dissertation Structure

To address these aims, objectives and research questions, the dissertation is structured as six interrelated chapters.

Chapter 1: Introduction This introductory chapter presents the background and context of healthcare architecture; the scope and objectives of the thesis, research questions and a brief description of each chapter. To initiate the discussion, it presents the challenges associated with the design of healthcare architecture, as well as recent developments and opportunities in realizing sustainable healthcare architecture.

17

Chapter 2: The Integrated Design Approach Having established the importance and necessity of sustainable healthcare architecture in Chapter 1, Chapter 2 focuses on how sustainable architecture may be realized through the integrated design process. By drawing from various sources, the essential elements of the integrated design process are discussed, in particular:

1. Who are the key stakeholders and why a multi-disciplinary team is needed;

2. The necessary mindset change required for them to be effective in the integrated design process;

3. The visioning and objective setting process and the sustainable design brief;

4. The integrated design process including team-based iterative processes.

Chapter 3: Khoo Teck Puat Hospotal - A Case Study This chapter builds upon the work introduced in previous chapters and as such explores them within the context of the Khoo Teck Puat Hospital (KTPH), a purported sustainable healthcare architecture in Singapore (Guenther and Vittori, 2008, p.p. 172-174), completed in 2010. As such, Chapter 3 will first provide the background of the KTPH project, followed by examining how through project visioning, objectives setting, team formation and organization, the KTPH project had aligned team members’ mindsets, attitude and commitment with a common purpose and shared values. This is done through a comprehensive study of the literature and project document, as well as through interviews with the key project team members involved.

Chapter 4: KTPH’s Integrated Design Process This chapter continues from the previous chapter with the examination of the KTPH design process by mapping it against a theoretical model of integrated design process. It is followed by an examination of the team-based iterative processes through the various design stages, in the process exploring the contribution from different project team members, including the client representatives, users, various building professionals, etc; the integrated design techniques such as small group research and all stakeholders’

18

workshops; integrated design tools such as computer building performance simulation and green rating tools, as well as the challenges encountered in the collaboration process.

Chapter 5: Conclusion In this chapter, the outcome of the integrated design process, i.e. KTPH as an example of sustainable healthcare architecture is presented, hence completing the evaluation of the relationship between integrated design and its outcome. In so doing, it validates the relevance and importance of the integrated design approach to healthcare architecture. It is followed by a discussion of the lessons learnt in the practice of integrated design. By drawing on the lessons learnt, the chapter concludes by providing some recommendations on further research areas that will contribute towards improving the theory and practice of integrated design approach.

1.5 The Key Challenges of Healthcare Architecture in Singapore

In 2009, the Laurence Berkley National Laboratory (LBNL) produced a report entitled High Performance Healthcare Buildings: A Roadmap to Improved Energy Efficiency (Singer and Tschudi, 2009). This report highlighted many of the challenges confronting healthcare facilities. Amongst these challenges, several stood out as having an important role in the design of healthcare architecture, and have prompted the discussion set in the Singapore context, as presented in section 1.5.1 to 1.5.2.

1.5.1 Challenges Related to the Provision of Medical Services 3

Medical services are often required to operate 24 hours a day, every day of the year. This leads to high overall energy intensity for hospital architecture. Prescribed operational needs, life-safety concerns and compliance with codes and standards often demand building services and equipment to be robust, reliable and with backup. Some of the issues relevant to Singapore healthcare facilities are summarized in Table 1.1.

3 Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to Improved Energy Efficiency. Lawrence Berkeley National Laboratory. pp 4.

19

Table 1.1

Challenges related to provision of medical services in Singapore

 

Challenges

1.

High Receptacle Loads: To provide good quality medical services, modern medical equipment and processes are required. Inevitably, energy is required for their operation, resulting in high receptacle and cooling loads (Singer and Tschudi, 2009). As a reference, BCA-NUS Building Information and Research Centre rated Singapore office building with total building energy efficiency of 147kWh/year/m 2 as ‘excellent’, and 348.35kWh/year/m 2 or more as ‘poor’. Using KTPH as a reference, if it is designed based on code requirement, its annual consumption is estimated to be 532.11kWh/year/m 2 (Toh, Y. H., project mechanical engineer for KTPH, file archive), which is 1.5time more than the office buildings rated as ‘poor’ in energy performance.

2.

Space Cooling for Tropical Climate: Due to the warm, humid tropical climate in Singapore, and due to the long operating hours, space cooling becomes one of the main contributing factors for high energy consumption in healthcare facilities in Singapore. If thermal comfort can be achieved by low- energy means, significant savings in terms energy consumption and operating expenses can be achieved. (Lai-Chuah, 2008)

3.

Needs for Infection Control: The need for infection control in hospitals, and hence high ventilation rate, leads to the need for large mechanical systems and high energy demand. Natural ventilation reduces energy consumption, but poses a question on thermal comfort and whether infection control is effective. (Infection control association, Singapore)

4.

High Energy Costs: As Singapore imports all her energy needs, any measure to reduce energy consumption be it through conservation, equipment efficiency or process innovation, contributes to national competitiveness, lowered costs, and better environment by mitigating carbon emission and combating climate change. The introduction of a national green rating system, the BCA Green Mark Scheme in January 2005, followed by mandatory compliance in 2007, illustrates Singapore’s resolve in bringing energy consumption in check. (National Energy Agency, Singapore; Building Control Authority, Singapore)

5.

Policy and Cost Control Considerations: For government-funded public hospitals, patients in different wards either pay medical expenses in full (ward A class), or subsidized between 20% (maxmimum subsidy in ward B1 class) and 80% (maximum subsidy in ward C class), depending on their financial means. As all Singaporeans are accessible to enjoy the subsidies, it is therefore essential that healthcare facilities are designed and operated to provide good quality medical services while minimizing public expenditure. In this regards, two immediate benefits that sustainable healthcare architecture may bring is reduced resource consumption and improved wellness for patient and staff. (Lai-Chuah, 2008; Lim, 2003)

1.5.2

Challenges

Related

to

Healthcare

Organization,

Structure

and

Culture 4

The complex functions in large scale healthcare facilities (Section 1.1) have to be managed, and its organization and operational structure can likewise be very complex. The organizational structure and culture of the healthcare organization and/or operator has a large influence on the design of healthcare architecture. Some of the issues relevant to Singapore healthcare facilities are summarized in Table 1.2.

4 Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to Improved Energy Efficiency, Lawrence Berkeley National Laboratory, p. 8.

20

Table 1.2

Challenges Related to Healthcare Organization, Structure and Culture

Challenges

1.

Regulatory and Operational Requirements: As health care is a life-and-death business, some of the high-energy applications are needed to meet the requirements of medical care, and will not be compromised. Its operational procedures are also subjected to strict regulatory requirements (Singer and Tschudi, 2009).

2.

Environmental Stewardship: Singapore healthcare sector has a long history of playing the role of environmental stewardship. For example, Changi General Hospital has a successful programme of cultivating gardens and vegetables on its roof garden (Verderber, 2010, pp. 162); Alexandra Hospital (AH) has embraced the notion of ‘healing gardens’ by cultivating lush landscaping within the hospital premise to provide respite for patients, staff and public (FuturArc, 2011 ). As the KTPH management team comprises largely from the AH team, the values to uphold environmental stewardship was brought over. Despite the high-energy nature of healthcare operation, the KTPH management team was resolute in setting high environmental performance target for the new KTPH (Guenther and Vittori, 2008, p.p. 172-174).

3.

Organizational Culture: The budget and decision structures of the usually complex healthcare organization, as well as its culture, will influence the value-decision such as the willingness (or lack of) to incur higher capital expenditure to achieve efficient or high-performance building. In addition, the nature of the healthcare industry may create a risk-averse and conservative culture, and a complex healthcare organizational structure may be besieged by bureaucracy or partisan-interests, resulting in a lack of consensus in decision-making. It takes strong courage and management will for healthcare management and administration to deviate from established practices and approaches to seek innovative solution to conflicting demands. It also requires from them the ability to mobilize and organize resources to put in place a project committee and sub-committees, empowered to take actions and make decisions (Singer and Tschudi, 2009).

1.6 Sustainable Healthcare Architecture in Singapore’s Context

Since the introduction of the concept of the ‘triple-bottom-line’ by John Elkington 5 , the concept has been widely understood and accepted as essentially “an assessment of social value and eco-efficiency in addition to the conventional economic/financial balance” (Szokolay, 2008, p. 322) 6 . The issues of sustainable healthcare architecture in Singapore’s context may hence be framed along the economic, social and environmental dimensions, and this three-dimensional framing is adopted for this dissertation. They are briefly discussed in Section 1.6.1 to 1.6.3, so as to provide the background as well as to highlight the opportunities for sustainable healthcare architecture Singapore.

5 The concept of ‘triple bottom line’ was first coined in 1998 by John Elkington in the book ‘Cannibals with Forks: the Triple Bottom Line of 21st Century Business’. 6 Guenther and Vittori (2008) has put forth the business case for sustainable healthcare the needs to balance multiple priorities and perspectives, represented by triple-bottom-line viewpoints of:

Strategist (represented by the CFO, who is concern with capital cost, revenue streams, operational efficiency, etc), Seeker (represented by the CEO, who is concern with market growth, business opportunities, leadership, etc), and the Citizen (represented by the COO, who is concern with community health and participation, staff relations/retention/recruitment, civic value, etc) (p. 107).

21

1.6.1

Economic Sustainability

Singapore’s healthcare system is ranked by World Health Organization as the best in Asia and six globally 7 . She has one of the lowest infant mortality rates but at the same time also amongst the lowest in total health care expenditure when compared to advanced economies in Asia (Gauld et al, 2006, pp. 331), if not the World (Lim, 2003, p.84). This is achieved by a combination of government funding, healthcare insurance and varying degrees of co-payment by individuals, as a result balancing good quality healthcare with restraint and responsible expenditure. Within such a healthcare economic system, the government is heavily involved in governance and administration, with public hospitals providing 80% of the hospital care. The reverse is true for primary care, with 80% of the services provided by private clinics (Gauld et al, 2006, p. 331).

In addition, the Singapore government places “a strong emphasis on fitness and health, evident in workplace-based fitness programmes, and anti-smoking and healthy food campaigns.” (Ibid., p. 332). Such a wellness philosophy is seen echoed in KTPH’s holistic model of care, in which emphasis on ‘pre-hospitalization’ and ‘post-hospitalization’ (promoting wellness) stages is supplemented by an efficient and effective ‘hospitalization’ stage (treating illness) (Liat, 2009; See Figure 1.2 and 1.3).

To achieve competitive pricing and affordable healthcare costs for patients, hospital management and administration have to focus on efficiency and cost control measures, such as lean and efficient operation and staffing, without compromising on the quality of medical care and services; this is very much embraced at KTPH. 8

7 WHO’s World Health Report in 2000 on health systems. 8 In chapter 6 ‘Efficiency’ of the book Evidence-based Design for Healthcare Facilities, Pille, E. and Richter, P. wrote about how process improvement e.g. Six Sigma was increasingly employed in the improvement and planning of healthcare facilities. In the case of KTPH, this is very much the case, with Six Sigma and the process philosophy of the Toyota Production System harnessed for process improvement (Design Business Case Study: Alexandra Hospital, 2009).

22

With the assurance of an equitable and sustainable healthcare economic system (Lim, 2003), and no doubt one that will continually to be improved upon to better serve the evolving society and communities of Singapore 9 , the next inter-related questions and the focus of this dissertation, i.e. sustainable healthcare architecture in the Singapore context, are essentially along the social and environmental dimensions.

essentially along the social and environmental dimensions. Figure 1.2 “ The typical compartmentalized, episodic

Figure 1.2 The typical compartmentalized, episodic model of care.Source: Liat, T. L. (2009), Planning for a Hassle Free Hospital.

Liat, T. L. (2009), Planning for a Hassle Free Hospital . Figure 1.3 ” Khoo Teck

Figure 1.3Khoo Teck Puat Hospital’s holistic ‘Head-To-Toe Lifelong Anticipatory Healthcare of Whole Person’ model”. Source: Liat, T. L. (2009), Planning for a Hassle Free Hospital.

9 Corporatization of government hospitals in Singapore to aim at efficient and price-competitive operation commenced in the mid-80s, and had largely been completed in the 90s. The re- structuring and clustering of healthcare organizations continued, with the latest restructuring exercise having taken place in 2008 with the formation of two clusters - the National Healthcare Group (NHG) and the Singapore Health Services (SingHealth) to provide vertically integrated health care, aimed at “making public healthcare more accessible to its patients”(MOH Holdings,

2009)

23

1.6.2

Social Sustainability

Opportunities in enhancing social sustainability in healthcare architecture rest in the following areas:

1. Enhancing the wellness of patients, clinicians and hospital staffs through a stress- reducing environment, as supported by evidence-based research.

2. A healthcare built environment serving as a sustainable public place for the community.

1.6.2.1 The Relationship between Human Wellness and Environment

Not only are healthcare facilities merely the premise for the practice of medical science and technology that provide patient safety and quality patient care, it should also be designed to “embrace the patient, family, and caregivers in a psycho-socially supportive therapeutic environment” (Smith and Watkins, 2010). The Therapeutic Environment theory stems from the fields of environmental psychology (the psycho-social effects of environment), psychoneuroimmunology (the effects of environment on the immune system), and neuroscience (how the brain perceives architecture)” (Ibid.), and researches have shown that provision of therapeutic environment can measurably improve well- being of patient, healthcare workers, and care givers, including:

1. Supporting clinical excellence in the treatment of the physical body (Ibid);

2. Supports the psycho-social and spiritual needs of the patient, family, and staff (Ibid);

3. Produces measurable positive effects on patients' clinical outcomes and staff effectiveness (Ibid).

Such evidence-based research have contributed to the rise of evidence-based design (EBD), a relatively new field of multi-disciplinary study that places importance in using

24

credible data to influence the design process, particularly in its application in healthcare design and operation (Ulrich, 1984, 1991, 1999, 2000, 2002, 2004, 2006). “EBD adds an objective dimension to subjective ideas about environmental influences on patients’ well- being, including light, space, noise, air quality, materials, traffic flow, triage procedures, infection control, ergonomics, aesthetics, navigation, and access to specialty services” (Millard, 2007, p. 267). There are more than 1,000 EBD research studies relating healthcare design to medical care and patient outcomes (McCullough, 2010). By leveraging on evidence-based practice in the field of medicine, EBD advocates using a body of knowledge supported by research to make decision on the patients’ and healthcare workers’ environment, with some examples listed in Table 1.3.

Table 1.3

Evidence-based design relevant to built environment

 

The built environment should not induce additional stress, but facilitates patients in devoting their

1.

energy to healing and recovery, e.g. healing environment; family-centred care environment, effect

of aesthetics, way finding, etc. 1, 2

 

The built environment should protect and support the well being of the healthcare clinicians and

2.

working staff, e.g. biophilic environments, workplace efficiency, etc. 1, 2

 

The built environment should not cause harm to the environment and ecology at large, i.e. the

3.

premise of environmental sustainability. 1

4.

Design to give patients, visitors and staff contact with nature. 3

5.

Design to give patients, staff and visitors views out of buildings. 3

 

Give all building occupants environmental comfort and control over that comfort, including heat,

6.

light and sound. 3

7.

Design to give patients privacy, dignity and company. 3

1 Verderber, 2010

2 McCullough, 2010

3 Lawson (2005), Evidence-Based Design for Healthcare

The rapidly growing body of works in EBD tends to focus on patient-benefits, staff- benefits and operational efficiency. Rosenberg noted that application of sustainability and EBD strategies often seem to operate in isolation from each other(Rosenberg, worldhealthdesgin.com). Integrating EBD with environmental sustainability in healthcare architecture presents both challenges and great opportunities in achieving sustainable healthcare architecture in a more integrated and holistic manner. In the KTPH case study, it shall be seen how the medical professionals and building

25

professionals had contributed their respective knowledge domains e.g. the notion of healing garden by the medical professionals, as informed by their practice of the same in their previous premise, Alexandra Hospital (AH), and the notion of bioclimatic, resource-efficient green building by the building professionals; and through the integrated design process, contributed to the eventual design outcomes in KTPH.

1.6.2.2 Sustaining Community through Healthy Public Place

Healthy hospitals’ (Walsh; in Guenther and Vittori, 2008, p. 390), i.e. hospitals not merely to treat illness but support and sustain human wellness, may possibly open up its premise to connect, engage and be enjoyed by its neighbourboods and communities. 10 For the case of KTPH, this relates to the surrounding public housing estates, community club, Yishun Town Centre and the Yishun Pond and public parks near its vicinity. Over time, a well-used public place is expected to build up a strong civic identity (Verderber, 2010, p. 45). An environmentally friendly and socially engaging hospital encourages community participation in environmental, social and healthcare programmes e.g. healthy living, community gardening, medical social works, etc, promoting community wellness while fostering environmental awareness. In this regards, KTPH again is used as a case study of a public hospital taking up such community and environmental stewardships (see Appendix XIV and XV).

1.6.3 Environmental Sustainability

In response to challenges posed by climate change, environmental degradation and depletion of resources, many green rating tools have been developed to guide the design of environmentally sustainable architecture. As best practices evolve, the green rating systems are updated. The UK-developed BREEAM, one of the earliest green rating tools

10 Tzonis, A.(2006) holds the view that while substantial knowledge advancement had been made “in designing sustainable ecological environments”, in terms of “sustainable social quality”, “(the) field to explore is enormous and the task of inquiry is just beginning”. He proposed to “explore and discover how decisions about the spatial structure of the environment as a communicator enable interactions”. The evidence-based design as informed by healthcare architecture and research such as space syntax by Bill Hillier (Hillier, 1999) appear to point towards this direction.

26

initiated (in 1990; see Figure 1.4), introduced the BREEAM Healthcare in 2008 to cater for the design of healthcare architecture. The US-developed LEED Healthcare has also been newly introduced in 2011. It was developed in close collaboration with Green Guide for Healthcare (GGHC), introduced in 2007, providing guidelines on both design and healthcare operation. Some other design guides or green rating tools for healthcare facilities are shown in Table 1.4. The list is not exhaustive. In addition, these tools are constantly being improved and new tools emerging.

tools are constantly being improved and new tools emerging. Figure 1.4 Comparisons of some green rating

Figure 1.4 Comparisons of some green rating systems for sustainable buildings Source: Bauer, M., Mösle, P., Schwarz, M. (2010)

27

Table 1.4

Sustainable design guides and green rating tools for healthcare facilities

1.

BRE’s BREEAM New Construction: Healthcare is an environmental assessment method and certification scheme for healthcare buildings in the UK (http://www.breeam.org/).

2.

Green Guide for Health Care which provides resources for voluntary, self-certifying metric toolkit of health-based best practices (http://www.gghc.org/).

3.

USGBC’s LEED for healthcare customized the popular LEED green building rating system to support healthcare building’s unique challenges.

 

The Strategic Energy Management Planning (SEMP) tools and resources by BetterBricks provide

4.

resources for hospital management and facility directors, healthcare designers, and energy service providers (http://www.betterbricks.com/ healthcare).

 

The public review draft of the proposed ASHRAE/ASHE Standard 189.2P for the design,

5.

construction and operation of sustainable high-performance health care facilities was launched in March, 2011 (http://www.ashe.org/advocacy/advisories/)

Situated in the tropics, Singapore needed its own green rating system in order to address the specific requirements in responding to the climatic, natural, economic, social, cultural political and national security constraints that Singapore faces (BCA) 11 . A national green rating system, namely the BCA Green Mark Scheme, was introduced in January 2005 to guide the design and operation of green buildings in Singapore. It is a matrix and point system, with four levels of achievement:

Green Mark Platinum (Highest)

Green Mark Gold Plus

Green Mark Gold

Green Mark certified (Lowest)

As a relatively new green rating system, there is no healthcare-specific Green Mark system. Green Mark Version 3.0 was adopted for KTPH’s design, with Green Mark Platinum set as the target to achieve. A key question is: is that considered as environmentally sustainable?

In ‘Trajectory of Environmentally Responsive Design’ (2006) by Integrative Design Collaborative & Regenesis, [environmentally] sustainableis defined as being at a

11 BCA Green Mark Scheme website [online] Available at: <http://www.bca.gov.sg/greenmark/ green_mark_buildings.html>

28

neutral, inflection point from degenerating to regenerating health(Ibid., p. 1; Figure 1.5). Anything less than that, even though it may be ‘Green’ or ‘High Performance’, simply means that it is better than conventional practice but still causes degeneration to the environment, albeit to a lesser degree. A restorative’ design or system is one that is able to “restore the capability of local natural systems to a healthy state of self organization(Ibid., p. 2), and ‘Regenerative’ design or system are an integral part of the process of life in that place(Ibid., p. 2). In a regenerative system, people, built-form and natural systems enter a healthy state of co-evolution. In this sense, not only is sustainable architecture one that seeks to restore human wellness in the social dimension, but as part of the natural systems, one that seeks to restore and regenerate natural health in the environmental dimension.

regenerate natural health in the environmental dimension. Figure 1.5 Trajectory of environmentally responsive design

Figure 1.5 Trajectory of environmentally responsive design Source: Integrative Design Collaborative and Regenesis (2006)

29

Some have therefore promoted the notion of ‘restorative environmental design’ (Kellert, 2004; Birkeland, 2002), by ‘extending the concept of ecological health to include humans in the ecological equation’ (Kellert, 2004, p. 3). Architecturally, this includes embracing nature in the built environment, which complements the inter-related notion of biophilic architecture (Ibid., Wilson, 1984; Kellert et al, 1993). The notion of ‘biophilia’ premised on human’s innate affinity with nature and living things, promoting human wellness and social sustainability in the process. In this regards, environmental and social sustainability may be seen as symbiotic. To relate to the healthcare context, natural systems may be embraced to achieve human wellness outcomes, in the process regenerating the natural systems. Set out to embrace nature for its therapeutic properties, KTPH again provides a case study demonstrating attempts in fostering natural systems.

1.6.4 Defining Sustainable Healthcare Architecture

By taking into account the various sustainability dimensions in the Singapore healthcare context (Section 1.6.1 on economic dimension, Section 1.6.2 on social dimension, Section 1.6.3 on environmental dimension), sustainable healthcare architecture may be defined as an integrated solution that addresses all three dimensions in a holistic manner (Figure

Eco-Design

Biophilic Built Environment

Built environment that integrates with

Evidence-Based Wellness

Community-Stewardship

natural and ecological systems Environmental Sustainability Social Economic Sustainability Sustainability Green
natural and ecological systems
Environmental
Sustainability
Social
Economic
Sustainability
Sustainability
Green Building
High-performance

Built environment that supports

Resource-efficient

integrated healthcare and social systems

Maximize passive strategies, e.g. NV

Figure 1.6 Model of sustainable healthcare architecture

30

1.6). As proposed, KTPH that was built in 2010 provides a case study for the examination and discussion of these sustainability dimensions (from Chapter 3 onwards). The immediate question is: what are the process challenges to be overcome before one is able to arrive at the outcomes of sustainable healthcare architecture? This is discussed in the next section.

1.7 Discussion: The Need to Integrate Inter-Disciplinary Knowledge

Section 1.5 of this dissertation presents the key challenges confronted in healthcare architecture, especially in large scale hospitals. These challenges are rooted in the complex functions and stringent operational requirements affecting human well-beings. It is followed by Section 1.6, which presents the opportunities in the Singapore context for healthcare architecture to advance the economic, social and environmental sustainability dimensions. Given such opportunities, the main challenges being confronted by the building professionals (including designers and project team members) in undertaking the design are as follows:

1. The knowledge domains required to address the economic, social, and environmental sustainability dimensions reside in different professional disciplines e.g. evidence-based studies on patient outcomes from the medical profession, space planning, building safety requirements and high-performance; green building design from the building professions; and natural systems from landscape designers and ecologists, etc.

2. The various disciplines need to propose and agree on the specific objectives and requirements to be achieved in the sustainable healthcare architecture. In so doing, they must resolve any conflict between these objectives and requirements, by asking the following questions: Are there trade-offs between these objectives? Are they mutually supportive? Are there inter-dependencies?

3. After the design objectives and requirements have been determined, a design process is needed to generate solutions. As the solutions generation is likely to

31

require knowledge input from different professional disciplines, a team-based, collaborative approach is not only advocated, but necessary. More pertinently, the solutions generated need to be integrated into a holistic, overall solution.

This team-based, collaborative approach is generally known as the integrated design approach, and some sources have advocated that it is particularly useful for the design of healthcare facilities (Guenther and Vittori, 2008, LEED 2009 for Healthcare, Green Guide for Health Care v2.2). The relevance of integrated design for healthcare architecture is examined in the next chapter. It starts by defining the integrated design approach, followed by presenting its relevance to healthcare architecture, before moving on to presenting the essential elements in an integrated design approach.

32

“An integrated design process creates opportunities for the design team to link the many parts of social, technical and earth systems into a coherently and mutually supportive whole systems.”

Bill Reed

(Integrated design process) provides the means to apply the design strategies and move society towards sustainability, one project at a time.”

society towards sustainability, one project at a time .” Alex Zimmerman Chapter 2.0: The Integrated Design

Alex Zimmerman

Chapter 2.0: The Integrated Design Approach

33

Chapter 2.0

The Integrated Design Approach

Chapter 1 presents the challenges in the design of sustainable healthcare architecture, in which knowledge inputs from the different disciplines need to be integrated in a holistic solution, through a collaborative, team-based process. Such is the premise of the integrated design approach. In this chapter, by drawing from literature, the following are presented:

1. The definition of the integrated design approach (Section 2.1);

2. The benefits of integrated design approach to healthcare architecture (Section

2.2);

3. The essential elements of integrated design approach (Section 2.3).

4. Discussion (Section 2.4).

2.1 The Definition of Integrated Design Approach

The ‘Roadmap for the Integrated Design Process’ (2007) defines the integrated design approach as providing “a means to explore and implement sustainable design principles effectively on a project while staying within budgetary and scheduling constraints.” (p. i) Using the term “integrative design”, 7group and Bill defines it as one that “optimizes the interrelationships between all the elements and entities associated with building projects in the service of efficient and effective use of resources” (7group) 12 . Known also as the “whole building design process”, Whole Building Design Guide website defines ‘integrated design’ as one that “includes the active and continuing participation of users, code officials, building technologists, cost consultants, civil engineers, mechanical and electrical engineers, structural engineers, specifications specialists, and consultants from many specialized fields.13 This dissertation takes the position that the above definitions refer to the same subject matter by taking slightly different perspectives; but their intent and purpose are the same. Hence, for simplicity, the term ‘integrated design’,

12 7group website (2011), Integrative Design. Internet WWW at: <http://www.sevengroup. com/integrative-design/#fragment-1> (Accessed 10.01.2012). 13 Engage the Integrated Design Process, WWW at: The Whole Building Design Guide. Internet WWW webpage at: <http://www.wbdg.org/index.php> (Accessed 24.06.2011. Revised 30.10.2010).

34

‘integrative design’ and ‘whole-system design’ as defined by various literature sources are referred to in this dissertation by the term ‘integrated design. Summarizing from these sources, the definitions of the integrated design approach for the purpose of this dissertation are as follows:

1. A team-based, collaborative design process which includes the active and continuing participation of users, building professionals, specialists, and stakeholders from other diverse but relevant disciplines;

2. To explore and implement design outcomes based on sustainable design principles, including economic, social and environmental sustainability considerations;

3. So as to achieve sustainable architecture as an end product that meets the sustainability objectives.

2.2

Benefits

Architecture

of

the

Integrated

Design

Approach

in

Healthcare

In chapter 6 Design Process of the book Sustainable Healthcare Architecture, Guenther and Vittori (2008) give a comprehensive account relating the benefits of the integrated design approach in delivering values to sustainable healthcare architecture. With supplementary support from other literature sources, the views are briefly explained in sections 2.2.1 to 2.2.5:

1. Increasing scale and complexity of healthcare facilities (Section 2.2.1);

2. Failure of traditional siloed and linear design process (Section 2.2.2);

3. The integrated design process allows a broad range of expertise to be integrated into a holistic solution through a collaborative process (Section 2.2.3);

4. The first outcome is the realization of the healthcare built environment as sustainable architecture (Section 2.2.4);

5. The second outcome is the building up of an ongoing learning culture within the healthcare organizations, with integrated design approach both providing supports and benefiting from such a culture (Section 2.2.5).

35

2.2.1

Increasing Scale & Complexity

Healthcare facilities are confronted with increasing scale and project complexity, including programmatic and regulatory complexity, site acquisition, environmental considerations, design & construction process, etc (Ibid., p 129). Some of these challenges confronting healthcare architecture in Singapore have been presented in Section 1.5 and 1.6.

2.2.2 Failure of Traditional Siloed and Linear Design Process

The advancement in modern technology and materials has led to ever-increasing level of sophistication and complexity in modern buildings, resulting in the need for more specialists in building projects. Unfortunately, under the intense commercial pressure, the building professionals have a tendency to perform their work with minimal interaction between disciplines, so as to complete their own ‘deliverables’ within a shortest possible time duration (7group and Reed, 2009; Table 2.1). Such traditional siloed and linear project delivery process is neither able to nor able to optimized

Table 2.1

General factors contributing to current fragmentary state of design practice (7group and Reed, 2009)

S/No.

Factors

1.

Specialization: Rapid advancement of technology and new materials has led to ever-increasing levels of sophistication and complexity in modern buildings, resulting in the need for more specialists in building projects, many of them responsible for and involved in only a part of the project or a specialized system. Furthermore, in the globalised world, it is not uncommon that many of the specialists are from a different geographical location, and practising in a different cultural and legislative context. The focus on each specialist’s own works often leads to a lack of concern for or connection to others’ work. In addition, due to the disconnectedness, they do not participate in the ‘problem selection’ stage of the early design process, leading to missed- opportunities (p. 9-11).

2.

‘Siloed optimization’: The fast-pace demand of modern lifestyles tends to result in highly efficient specialists, who are skilled in optimizing the design of their own disciplines in isolation. This is often carried out with minimum contact between the project team members. As building systems often require input from different disciplines, such silo-mentality negates the opportunities to optimize within a building system; far less between building systems (p. 9-11).

3.

Disconnect between design and construction professionals: The design intended to be built is represented in design documentation. The first opportunity for the builders to read the design documentation is usually during the tender process. Soon after the award of tender, the construction starts, and there is effectively very little time given to the contractor to understand the design. “The (construction) process more closely resembles assembly than integration…we often find redundancies, unnecessary costs, and a great deal of wasted time and effort.” (p. 10)

36

building performance, nor keep pace with rapid innovation in medical sciences and technologies (Guenther and Vittori, 2008, p. 129), as they do not invest time in learning. This is further exacerbate by the increasingly litigatious environments; in response many professionals have resorted to design by basing on conservative (often rule-of-thumb) code-compliant norms (7group and Reed, 2009, p. 9 11; see also Table 2.1).

2.2.3 The Integrated Design Process

The alternative design process, i.e. the purported integrated design process is one that seeks to:

1. Harness contributions from a multi-disciplinary team (Guenther and Vittori, 2008, p. 130; Yudelson, 2009, p. 53; LEED for Healthcare 2009, p. 89, Green Guide for Health Care v2.2, p. 5-3);

2. Establish new, inclusive and collaborative mindset (Guenther and Vittori, 2008, p. 131; 7group and Bill, 2009, p. 52);

3. Set bold vision and objectives (Guenther and Vittori, 2008, pp. 130; Yudelson, 2009, p. 46);

4. Employ iterative design process through group workshops and design charettes (Guenther and Vittori, 2008, pp. 130; 7group and Bill, 2009, pp. 68);

5. After delivering the project, continue to learn from it through post-occupancy feedback loops so as to inform future design (7group and Bill, 2009, p. 312-313).

A comparison between the integrated design process and the conventional design process, as collated and summarized from various literature sources is shown in Table

2.2.

37

Table 2.2

Comparison between Integrated and Conventional Design Processes

Integrated Design Process

Conventional Design Process

Establish clear and shared goals and values 3

Lack clear and shared goals and values 4

Front-loaded time and energy invested early 1 ; Intensive design process begins early at the concept stage with charettes, workshops, etc. 3

Involves team members only when essential 1 ; Activities become more intense towards documentation stage with design coordination, resolve conflicts 1

Engages in individual research as well as group iteration process, e.g. charettes, workshops, etc. 1, 2

Linear or siloed process 1, 2, 4 ; limited group contribution in design formulation.

Emphasis on ongoing learning and research 1

Preordained sequence of events

Adopt ‘whole system thinking’ 1 or ‘whole-building approach’; allow for full optimization. 1

Focuses on efficient design of individual systems in isolationlimited to constrained optimization 1

Seeks synergies 1

Diminish opportunity for synergies 1 ; poor communications 4

Life cycle costing 1 ; consider budget as a whole, allowing higher cost but better design in one system (e.g. façade) to be offset by savings from a system (e.g. space cooling or heating).

Considers budget as isolated, independent systems.

Innovate by applying existing technologies in new ways, or incorporate group- sanctioned new technologies to solve problems identified.

Avoid new and unproven technologies to avoid risk of failure or blame by others.

Preparation of two, three or more options in concept design alternatives, supported by energy simulations.

Concept design was formulated based on functions or image; without thorough considerations for environmental and social sustainability issues.

Decisions involve all the key stakeholders 1

Decisions are made by a few decision makers 1

Process continues through post-occupancy 1

Typically finished when construction is complete 1

References:

1 Busby Perkins+Will and Stantec Consulting, (2007). Roadmap for the Integrated Design Process. p. 8.

2 7Group, Reed, B., (2009). The Integrative Design Guide to Green Building: Redefining the Practice of Sustainability. p. 9.

3 Yudelson, J., (2009). Green Building through Integrated Design. p. 46.

4 ANSI MTS 1.0 WSIP Guide, (2007). Whole System Integrated Process Guide. p. 3-4.

2.2.4 Achieving Sustainable Healthcare Architecture

To Guenther and Vittori (2008), the main intended outcome of the integrated design approach is sustainable healthcare architecture; one that optimizes building site planning, envelope design, systems design and material selection in a holistic manner, “reducing initial cost and delivering sustained, improved performance.” (Ibid., p. 129; Bokalders and Block, 2010), providing positive outcomes to the community and human wellness, as well as ecologically restorative and/or regenerative. Briefly defined in Section 1.6.4, the notion of sustainable healthcare architecture in the Singapore context is worthy to be revisited in Section 2.3.5, after the integrated design approach has been presented.

38

2.2.5

Learning Organization

Guenther and Vittori (2008) further suggested that healthcare organizations should indeed strive to be learning organizations, imbue with a culture that values continual learning and improvement, and engages all its members in doing so. By engaging the integrated design process, the healthcare organization may endeavour to embody it’s project vision and goals into the architectural design (ibid., p. 130), achieving synergy and integration between built environment and operations.

Having established the benefits of the integrated design approach to achieving sustainable healthcare architecture, the next section discusses the essential elements of the integrated design approach.

2.3

Essential

Healthcare Architecture

Elements

of

the

Integrated

Design

Approach

for

This section expands on the integrated design approach for healthcare architecture by examining the following:

1. The multi-disciplinary project team and the expertise they need to bring to bear on the project (Section 2.3.1);

2. Mindset change that is required among the project team members in order to be effective in achieving integrated design (Section 2.3.2);

3. The integrated design process: What the project team members need to do right (Section 2.3.3);

4. Tools and techniques: What are the tools and techniques that support integrated design? (Section 2.3.4);

5. The integrated design product: What are the expected outcomes of integrated design? (Section 2.3.5).

39

2.3.1

The Multi-Disciplinary Project Team

The integrated design approach advocates at bringing together, at an early stage, all key stakeholders, e.g. owner, management, building designers (e.g. architects, civil & structural engineers, mechanical and electrical engineers, landscape designers, etc) consultants (e.g. cost, lighting, acoustic, façade, green design, etc), builders, users, operators, and perhaps even community representatives, to identify common goals and objectives of the hospital project (Guenther and Vittori, 2008). This is because no one party has all the knowledge of the design problems, especially for a large, complex hospital. Without a proper brief formulation process at an early stage, the opportunity for deriving a holistic, integrated solution will quickly diminish as project time is expended (Ibid., Section 1.7).

A suggested list of members for an integrated project team is given in LEED 2009 for

Healthcare (Figure 2.1). The organization of the team is discussed in Section 2.3.3.1.

organization of the team is discussed in Section 2.3.3.1. Figure 2.1 Multi-disciplinary project team for healthcare

Figure 2.1 Multi-disciplinary project team for healthcare project Source: LEED 2009 for Healthcare (New Construction & Major Renovations)

To balance sustainability priorities, it is often necessary to include non-building experts

in the team. For the case of sustainable healthcare facilities, it is essential to include in the

project team the representatives from the medical professionals, e.g. clinicians, nursing

40

leaders and operational managers. Not only are they expected to share knowledge and experience, as a result providing insights on how work in the healthcare facilities is done today, they are expected to think through how work can be done better, hence providing foresight for the next 10 to 15 years (Pille and Richter, in McCullough, 2010, p. 16, 119). After the myriad of clinical and operational requirements had been identified, they need to be put together spatially and systemically, and resolved with other building requirements.

Multi-disciplinary problems that require spatial and whole-system solution Amongst the established building professionals, architects as “three-dimensional problem solvers” (Williams, 2007, p. 14), are the most suited in leading the team of building professionals to “devise an integrated solution to a whole cluster of requirements.” (Lawson, 2005, p. 59) In his book ‘How Designers Think: The Design Process Demystified’, Bryan Lawson proposes a three-dimensional model of design problems to represent the range of design problems, issues or constraints that building designers need to grapple with (Figure 2.2). They include design problems generated from the designers’ own knowledge, as well as those from building regulations (legislator), clients and users. 14

These problems may be internal, e.g. designer’s own set of values; or external, e.g. fire safety measures stipulated in building authorities’ planning requirements. In addition, further requirements are imposed from: Purpose of the building project (radical); practical issues such as ease of construction, cost, and availability of technology (practical); visual organization e.g. massing, proportion, texture, colour, etc; and the expressive qualities and perceptive interpretation of the design (symbolic).

14 In the case of KTPH, clients are represented by the hospital management (Alexandra Health) and the government (Ministry of Health), which is the policy maker and funding agency. The users include the clinicians, nursing leaders, laboratory leaders, office administrators, operational managers, etc.

41

Figure 2.2 Bryan Lawson’s model of design problems or constraints Source: Lawson, B. (2005). How

Figure 2.2 Bryan Lawson’s model of design problems or constraints Source: Lawson, B. (2005). How Designers Think: The Design Process Demystified, p 106.

The whole cluster of design problems requires holistic solution finding with design iteration involving different experts, balancing one requirement versus another, in the process seeking to find synergies between these requirements. This is the premise of integrated design process, presented in Sub-section 2.2.3. 15

2.3.2 Mind Set Change: The Need for a Whole-System Mental Model

Before moving on to the presentation of the integrated design process and tools, it is important to emphasize on the need for mindset change among the integrated design team members (Reed, Todd and Malin, 2005; Reed in Guenther and Vittori, 2008, pp. 132). At this juncture, it is useful to refer to the model developed by Bill Reed and Barbra

15 Lawson has also put it that, “(design) inevitably involves subjective value judgement” (2005, p. 124), and as “three-dimensional problem solvers” in control of the ‘primary (design) generator’ (ibid), the architect plays a highly influential role in perpetuating the values in the design solution, but it also comes with heavy responsibilities in the success of the integrated design process, e.g. to adopt an open mind and listen to views (and values) offered by other team members; “it demands that architects fundamentally alter their role. But giving up control goes against everything architects are taught” (Deutsch, 2011, p. 136). This may impose hurdles in the practice of integrated design, so a critical self-examination in architectural education and practice is warranted.

42

Batshalom (Reed, Todd and Malin, 2005; Guenther and Vittori, 2008, pp. 131-135) as shown in Figure 2.3. It clarifies the relationship between mental model (mindset, attitude and will), process (design, iterative analysis, workshop, charrette), tools (green rating tools, design guides, benchmarks, modeling programs), and products/technologies (building components, technologies, techniques, and the built environment as end product).

The siloed and linear traditional mode of thinking and design approach needs to be replaced by a mental model centred on whole-system thinking (Reed, Todd and Malin, 2005). It is premised on seeing not only the parts, but the whole; and not only what the system does, but what is the purpose of the system, or how does the system contributes to larger whole (Ibid).

or how does the system contributes to larger whole (Ibid). Figure 2.3 The new mental model

Figure 2.3 The new mental model for integrative design Source: Barbra Batshalom and Bill Reed (Reed, Todd and Malin, 2005, p. 17).

Attitude of the project team members Even with the multi-disciplinary project team in place, without the right team attitude, gaps in communication and sharing of knowledge and information are likely to be encountered (Figure 2.4). Many integrated design guides hence advocate the needs to cultivate positive, inclusive, collaborative and trusting attitudes among integrated design team members. These attitude attributes tend to foster a group dynamics that allows the design team to generate design outcomes “beyond the abilities of the

43

collective individual talents” (Lawson, 2005, p. 242). A summary of these attributes from various sources is shown in Table 2.3.

attributes from various sources is shown in Table 2.3. Figure 2.4 Zeisel’s user -needs gap model

Figure 2.4 Zeisel’s user-needs gap model Source: Lawson, B. (2005). How Designers Think: The Design Process Demystified. p 86.

Table 2.3

Positive attitudes necessary among the integrated design team members

S/No.

Factors

1.

Clear leadership 2 ;

2.

Inclusion and collaboration 1 ; everyone buys in and participate 3

3.

Outcome oriented 1 ; set stretch goals 3 ; commit to zero-cost increase 3

4.

Trust and transparency 1 ; social team-building 2

5.

Open-mindedness and creativity 1 ;

6.

Rigour and attention to details 1 ;

7.

Continuous learning and improvement 1 ; team building through teaching and learning 2

References:

1 Busby Perkins+Will and Stantec Consulting, (2007). Roadmap for the Integrated Design Process. p. 9.

2 7Group and Reed, (2009). The Integrative Design Guide to Green Building: Redefining the Practice of Sustainability. p. 30-

31.

2.3.3 Integrated Design Process

The right mindset needs to be supported by the right process. The Whole Systems Integrated Process (WSIP, 2007) as recommended in LEED 2009 for Healthcare (p. 93) is used in this dissertation as the IDP reference, supported and complimented by other literature references as and when necessary. The WSIP (2007) is “intended as a standard

44

guideline to support the building industry in the practice of integrative design” (p. 1) 16 , and its purpose is to provide a common reference for “all practitioners (architects, builders, designers, engineers, landscape architects, ecologists, clients, manufacturers, and so on) in support of process changes needed to effectively realize cost savings, deeper understanding of human and environmental interrelationships, and an improved environment for all living systems – human, other biological, and earth systems.” (Ibid., p. 1) Based on WSIP (2007, p. 8), the process stages in IDP may be categorized into six stages (see Table 2.4), presented in Section 2.2.3.1 to 2.2.3.6.

Table 2.4

WSIP Process Stages (2007, p.8)

Stage

Elements

1. Team Formation

“Fully engage Client in the design decision process.”

“Assemble the right team.” Key attributes in team formation is ‘teachable attitude’; members come on board not as experts but co-learners.

2. Visioning

“Align team around basic Aspirations, a Core Purpose, and Core Values.”

3. Objectives Setting

“Identify key systems to be addressed that will most benefit the environment and project”

“Commit to specific measurable goals for key systems”

Compile into a Sustainable design brief Key attributes in objective setting is to involve all participants, including the main financial decision maker, not unempowered representative. Also, identify champions for the objectives and issues.

4. Design Iteration

“Optimization of the design of systems” Key attributes in objective setting is to “understand and make best use of key systems in relationship to each other, to the goals, and to the core purpose”, and “Iterate ideas and systems relationships among team with all participants, including the main financial decision maker.”

5. Construction &

“Follow through during the Construction Process.”

Commissioning

“Commission the project.”

6. Post-occupancy

“Maintain the system.”

Feedback Loops

“Measure performance and respond to feedback - adjust key aspects of the system accordingly.”

16 Whole System Integration Process (WSIP, 2007), The Institute for Market Transformation to Sustainability, Washington.

45

2.3.3.1

Team Formation and Organization

The need for multi-disciplinary team formation has been covered in Section 2.3.1. However, the team structure and organization and how effective each team members play out their role is very important in driving the process forward. The ‘Road Map for the Integrated Design Process’ (IDP Road Map; Busby Perkins+Will and Stantec Consulting, 2007) proposes that the integrated design team (IDT) be formed as early as practicable. In principle, a typical IDT comprises the following (p. 15):

1. Client: The client takes an active role throughout the design process.

2. Expertise/Stakeholders: A broad range of expertise and stakeholder perspectives is present.

3. Team Leader: A team leader (champion) is responsible for motivating the team and coordinating the project from pre-design through to occupancy.

4. Facilitator: An experienced facilitator is engaged to help guide the process.

5. Core Project Team: The core group of team members remains intact for the duration of the project.

6. Collaborative: Team members collaborate well.

The multi-disciplinary core project team is responsible to collaborate and drive the project forward, as well as to identify and bring in additional team members with relevant expertise that support the project (Ibid. p. 15-17). Table 2.5 provides a basic summary of the recommended core project team members, additional members and description of their expected roles. A more detailed role of the various members throughout the project stages as provide in IDP Roadmap is shown in Appendix I.

To facilitate the collaborative spirit among the team members, the IDP Roadmap recommends two additional roles not usually found in traditional team organization:

1. Facilitator: The IDP Facilitator manages the integrated design process. He/she may be one of the project core team members, e.g. project manager or architect, or it may comprise a team, but the most important attribute skill sets they bring to

46

bear are in facilitation and group dynamics, and they must have a good knowledge of the ‘integrated design process’ (IDP) (IDP Roadmap 2007, p. 17). 2. Champion: The Champion is aligned with the vision of the project and is someone who is able to empower the team, understand the political and organizational barriers and is able to overcome them. The Champion may also be the Facilitator (IDP Roadmap 2007, p. 17).

A comparison between the conventional team organization and the IDP team organization is shown in Figures 2.5 and 2.6 (IDP Road Map, 2007, p. 18).

Table 2.5

Core Integrated Project Team Members (IDP Road Map, 2007, p.15-17, Appendix B)

Core Team Member

Role and Expertise

1. Client or owner’s representative

With expertise in operations management

With expertise in facilities management

2. Project manager

Manages project schedule, team communication and control of budget

3. Architect

Site planning and response to climate, natural and physical context

Space planning to meet programmatic and authority requirements

Form, envelope design, visual and aesthetics design to meet client/user

aspirations

4. IDP facilitator

Facilitates workshops. May be one of the team member with the

necessary facilitation skills.

5. Champion (optional)

Align with the project vision and empowers the team

6. Structural engineer

Structural system and choices that impact form and massing

Understands the inter-relationship between structural, architectural and

spatial programmes, and mechanical and electrical systems

7. Mechanical engineer

With expertise in simulation: energy modeling, thermal comfort analysis,

and/ or CFD simulations.

With expertise in energy analysis: an energy engineer and/or bioclimatic

engineer may be required in order to cover the necessary areas of

expertise, such as: passive solar design, renewable energy technologies,

and hybridtech strategies.

8. Electrical engineer

Provide input on energy systems, lighting/daylight design, etc.

9. Green design specialist

Provides input on energy-efficient and energy generation options.

Provides support on green design processes and tools.

10. Civil engineer

With expertise in: stormwater, groundwater, rainwater, and/or

wastewater systems.

11. Facilities manager/

Lessons learnt on operating other buildings

Building operator

Participate in workshops, review design and documentation

12. Green design specialist

Knowledge and advise on green design strategies and resources

13. Cost consultant

With experience in life-cycle costing

14. Landscape architect

Provide input on landscape design, habitat preservation or restoration

15. General contractor or construction manager.

Provide input on construction methods, materials, etc. Support the green

design strategies during construction execution.

47

Table 2.6

Additional

Integrated

Project

Team

Members

(IDP

Road

Map,

2007,

p.15-17,

Appendix B)

 

Additional Member

1. Ecologist

9. Commissioning agent

2. Occupants’ or users’ representatives

 

10. Marketing expert

3. Building program representative

 

11. Surveyor

4. Planning/regulatory/code

approvals

agencies

12. Valuation/appraisal professional

reps

5. Interior designer/ materials consultant

 

13. Controls specialist

6. Lighting or daylighting specialist

 

14. Other experts as required (e.g., natural

 

ventilation, thermal storage, acoustic)

7. Building program representative

 

15. Academics and/or students with knowledge of

 

a relevant subject

8. Soils or geotechnical engineer

 

16. Members of the community who are affected

 

by the project.

of the community who are affected   by the project. Figure 2.5 Conventional design team organization

Figure 2.5 Conventional design team organization Source: Roadmap for the Integrated Design Process. p. 18

Source: Roadmap for the Integrated Design Process. p. 18 Figure 2.6 Integrated design team organization Source:

Figure 2.6 Integrated design team organization Source: Roadmap for the Integrated Design Process. p. 18

48

2.3.3.2

Visioning

The visioning exercise provides the opportunity to align team members’ mindsets, attitude (as discussed in Section 2.3.2) and will or commitment to a common purpose and shared values. For healthcare organizations, this also provides the opportunity to align its long-term health vision and mission to serve as the navigation beacons to guide the integrated project team’s design (Guenther and Vittori, 2008).

2.3.3.3 Objectives Setting

Visions need to be supported by specific design objectives establish early in the project. To achieve balanced objectives, one recommendation is to guide the objective and goal formulation by taking the triple bottom line approach to sustainable development (Figure 2.7; Yudelson, 2009).

to sustainable development (Figure 2.7; Yudelson, 2009). Figure 2.7 Triple Bottom Line approach goal setting for

Figure 2.7 Triple Bottom Line approach goal setting for a project visioning session Source: Yudelson (2009). Green Building through Integrated Design. p. 147.

For healthcare project, this may include setting objectives such as:

49

1.

Economic sustainability: Setting high-performance goals that raise the bar or challenge the status quo, by specifying measurable targets such as ‘reduce energy consumption by 50% as compared to the baseline’ (Yudelson, 2009).

2. Social sustainability: Basing on evidence-based studies to improve environmental supportive qualities, clinical, service, and operational efficiencies; as a result enhancing social sustainability (McCullough, 2010)

3. Environmental Sustainability: Through integrating natural systems with built environment, (Kellert, 2004; Wilson, 1984; Kellert et al, 1993)

The vision and objectives shall not, however, become prescriptive, or worse, describe the solution, in so doing giving little room for designers to seek creative solution (Lawson 2004; Yudelson, 2009).

2.3.3.4 Design Iteration

Design iteration is a key feature in any IDP methodologies. WSIP (2007) emphasized the need to alternate between individual or small group research activities by participating parties (represented by the coloured bars in Figure 2.8) and team charrettes or workshop sessions participated by key stakeholders (represented by the blue dots in Figure 2.8). These are denoted as R1 to R4 and W1 to W7, and their iterative activities are summarized in Table 2.7.

and their iterative activities are summarized in Table 2.7. W1 W2 W3 W4 W5 W6 W7

W1

W2

W3

W4 W5

W6

W7

R1 R2 R3 R4
R1
R2
R3
R4

Figure 2.8 Integrative design process. Adapted from WSIP (2007).

50

Table 2.7

IDP: Research and workshop activities for healthcare architecture

 

Stage

Elements

R1:

Research/

Preliminary research, e.g. “identify base condition, context of project,” and sustainability opportunities; project programming; preliminary climatic studies, etc.

Analysis #1

W1: Workshop/

Visioning exercise involving all key stakeholders

 

Charrette #1

“Goal Setting and alignment of purpose/objectives among all participants.”

R2:

Research/

Continue research, e.g. establish comparative benchmarks, envelope and shading study, energy modeling, water management studies, clinical and operational workflow studies, space planning, circulation analysis, investigation of structural system, life cycle cost studies, etc.

Test initial concept for feasibility

Analysis #2

 

W2: Workshop/

Generate or iterate concept design or early schematic design through charrettes.

 

Charrette #2

“Review integrative cost bundling studies.”

 

Confirm with client the alignment of project with vision and objectives.

 

Schematic design: “Alignment of research and integration of design.”

R3:

Research/

Iterate design at more detailed levels, optimize system designs.

Analysis #3

“Review integrative cost bundling studies.”

Use metric, benchmark and green rating tools to test design.

 

Perform simulation studies.

 

Mid schematic design: “Fine-tuned refinement of the design and definitive inclusion of sustainability objectives with supporting data.”

W3: Workshop/

“Confirm the alignment of Client, Design, and Construction (or Cost Estimating) team around the objectives and aspirations.”

“Continue refining the integration of systems.”

 

Charrette #3

 

“Refine the Design and/or schedule the refining meeting and research process to get there,” e.g. confirm detailed layout plan with users.

 

“Continue to refine modeling and design.”

R4:

Research/

“Continue to test design concepts against the Core Purpose, Design Drivers, and Metrics and Benchmarks.”

Analysis #4

“Review any Integrative Cost Bundling Studies in process continuous Value Engineering.”

“Begin documentation process for rating system.”

 

“Build performance measurement and feedback loops into project.”

W4: Workshop #4 W5: Workshop #5

Late Schematic Design / Early Design Development.”

Sign-off workshop; tie-up loose ends.

W6: Workshop #6/ Construction Documentation

Detailed review of Drawings and Specifications

“Address non-building related sustainability issues.”

Refine documentation; continue value engineering; green rating documentation.

W7: Workshop #7/ Bidding & Negotiations

Pre-bid & Post Award Conferences to explain unique aspects of project Detailed review of Drawings and Specifications

“Address non-building related sustainability issues.”

Refine documentation; continue value engineering; green rating documentation.

Adapted from Whole Systems Integrated Process Guide (2007)

51

In ‘Strategies for integrative building design’, van der Aa, Heiselberg and Perino (2011) proposed a more detailed iterative process during the schematic design (SD) phase and design development (DD) phase. They proposed that design iteration shall progress from ‘concept design’ phase to ‘system design’ phase, and eventually to ‘component design’ phase (Figure 2.9). In the concept design phase, broad strategies are considered, including response to local climate (Ibid.). For sustainable healthcare architecture, other considerations at this phase may include programmatic requirements, regulatory requirements, and opportunities for ecological integration with the surrounding. In the system design phase, specific architectural and technical solutions are proposed, supported by design calculations and simulations. In the process, the design team members should seek opportunity for design integration of systems (Ibid.). The component design phase takes place in WSIP 2007’s design development (DD) stage, which seeks to confirm the system design, before proceeding to the design and selection of actual building components.

Research/Analysis Workshops/ Decisions SDDD
Research/Analysis
Workshops/
Decisions
SDDD

Figure 2.9 Iterative processes as proposed in ‘Strategies for integrative building design (van der Aa, Heiselberg and Perino, 2011). Text in red added for referencing with WSIP (2007).

van der Aa, Heiselberg and Perino (2011) highlight that the integrated design process is characterized by the iteration loops (Figure 2.10), providing “problem-oriented analyses of design alternatives and optimization…and taking into consideration input from other

52

specialists, influences from context and society that provide possibilities and/or limitations to design solutions as well as evaluates the solutions according to the design goals and criteria” (ibid., p. 8). There are many alternative theories regarding the iteration loops or process, which are presented in Appendix II. The position taken in this dissertation is that it is not advisable to be overly prescriptive; as expounded by Lawson (2005), “there is no infallibly good way of designing. In design the solution is not just the logical outcome of the problem, and there is therefore no sequence of operations which will guarantee a result” (p.p. 123-124).

which will guarantee a result” (p.p. 123 -124). Figure 2.10 ‘Iteration loops’ as proposed in

Figure 2.10 ‘Iteration loops’ as proposed in ‘Strategies for integrative building design’ (van der Aa, Heiselberg and Perino, 2011). [This author is of the view that ‘Coal’ in the diagramme is a typological error and show read as ‘Goal’ instead].

Both the Integrated design process (WSIP, 2007; Figure 2.8) and the Iterative process (van der Aa, Heiselberg and Perino, 2011; Figure 2.9) are used as models to examine the KTPH integrated design process.

2.3.3.5 Construction & Commissioning

Depending on the type of contract procurement method, the contractor may join the project team earlier or only at this stage. Again, an alignment between client, design team, stakeholders and contractor is required. Construction through to commissioning takes place at this stage.

53

2.3.3.6

Post Occupancy Feedback Loops

After proper handing over of building and facilities, the operations and maintenance of the facilities are carried out by trained personnel, based on sustainable principles. Building monitoring systems begin to measure and trend building performance, and post-occupancy evaluations are conducted to compare design assumptions and actual usage. The owner, design team continue to receive feedback on the systems’ data (building, energy, water, landscape, habitat, etc), so that the information gained can be studied, analyzed and form evidence-based studies to inform future design. This attribute of a continuous learning culture in the integrated design process augurs well with healthcare organizations that strive to be learning organizations, as presented earlier in Section 2.2 and 2.2.5, particularly in studies relating environment to human wellness.

2.3.3.7 Comparison between IDP and Linear Design Process

Before moving on to discuss about the IDP tools and techniques, a comparison between the IDP and linear design process (LDP) will provide clarity on the difference between IDP and LDP. With reference to Figure 2.11, the IDP is contrasted against LDP as follows (Figure 2.11):

1. Activities are front loaded for IDP, and the reverse for LDP.

2. Longer time duration in schematic design (SD) when compared to design development (DD) and construction documentation (CD) for IDP; short SD, long DD and CD for LDP.

3. For IDP, intense team collaboration, workshops and individual/small group research are held from the start, gradually tapering off near DD; for LDP, activities start slow but begins to peak at DD, and probably continues through CD stage. Meetings are held focusing on individual disciplines.

4. Continuous value engineering (VE) for IDP, sporadic and intense during bid and negotiation for LDP.

54

5.

VE for IDP focuses on system synergy, VE for LDP focuses on eliminating features to reduce cost.

VE for LDP focuses on eliminating features to reduce cost. Figure 2.11 Integrative design process versus

Figure 2.11 Integrative design process versus linear design process. Source: WSIP (2007)

2.3.4 Tools and Techniques that Support Integrated Design

The integrated design process needs to be facilitated by design tools to inform team- based design decisions, as well as design techniques to facilitate team-based collaboration. These are briefly presented in the sub-sections 2.2.4.1 and 2.2.4.2.

2.3.4.1 Integrated Design Tools

During the integrated design process, various tools may be utilized to permit informed decision-making. Many of such tools are becoming widely available (Reed, Todd and Malin, 2005). Some of the tools relevant for healthcare architecture include:

1. Green rating tools, e.g. BREEAM Healthcare, LEED for Healthcare, Green Mark, etc.

2. Green design guides, e.g. Green Guide for Health (GGHC), Practice Greenhealth, etc.

55

3.

Scale modeling tools, e.g. wind tunnel test;

4. Computer modeling tools, e.g. energy modeling, climatic simulation, computational fluid dynamics (CFD) simulations, etc;

5. Life cycle costing and Life cycle assessment tools, e.g. Building for Environmental and Economic Sustainability (BEES), etc.

6. Digital design collaboration tools, e.g. building information modeling (BIM).

Green rating tools (GRT) had been briefly discussed in 1.6.3. Those tailored for healthcare facilities are usually jointly developed and endorsed by both building and healthcare industries and/or authorities (e.g. BREEAM Healthcare, LEED Healthcare). GRT or metrics are primarily used as building performance metric to set design objectives for the project (WSIP, 2007), but may also be used as systematic frameworks to guide and align the project team members (IDP Roadmap, 2007). GRT provide a commonly accepted standard for assessing green buildings in their respective home markets (Yudelson, 2009), and widespread industry participation in a prevalent green rating system also allows building design parameters and best practices to be captured in a central database (Ibid., 2009). Over time this is a form of learning loops to allow the building industry to progressively improve upon the sustainable performance of its building design. Other forms of tools such as Green design guides e.g. GGHC are typically self-assessment metric toolkits to provide objective criteria based on best practices in which “designers, owners, and operators can use to guide and evaluate their progress towards high performance healing environments” (GGHC version 2.2, p. 1-1).

Scale and computer modeling tools allow the building performance of different design iteration to be ‘predicted’ through simulation, so that informed design decisions can be made (IDP Roadmap, p. 15). Currently, the common modeling tools used in the design process includes climatic, sun path and shading analysis software (Autodesk Ecotect; Integrated Environmental Solutions, etc); wind tunnel and CFD software that simulates air buoyancy and air movement which is useful when strategies involving natural ventilation are considered (Phoenix; Fluent; Integrated Environmental Solutions, etc); and energy modeling software which is playing an increasingly important role in

56

integrated design process, as it allows the different contributing factors that affect energy performance of the building to be simulated to obtain a combined outcome, in the process enhancing the project teamsunderstanding of project opportunities and constraints (Hatten, Betterbricks). The utilization of computer modeling tools is gaining momentum in Singapore in recent years, as encouraged by BCA Green Mark scheme which credit points to aptly applied energy modeling and other forms of simulations (BCA). 17

Life cycle cost (LCC) provides consideration of cost based on whole-life principle, which includes considerations for initial capital expenditure as well as costs associated to maintenance, operation and disposal (Riggs, 1982). The use of LCC tools facilitate the IDP project team by allowing decisions to be made based on the long-term cost impact of each iteration option. The parameters of LCC need to be defined, e.g. whether it considers only building operation, or also takes into account human productivity (Fuller, 2010). Life cycle assessment (LCA) tools such as ISO 14040 (2006) assesses environmental impact of the entire life cycle of a development, including considerations materials processing, manufacture, distribution, use, repair, maintenance, disposal and/or recycling (Ibid.).

Building information modeling (BIM) is slated to replace computed aided-design (CAD) as a design and documentation tool. Instead of representing buildings as lines and shapes, BIM allows a building design to be represented by virtual components with parametric properties that may be manipulated in the design process (Krygiel and Nies, 2008). What is perhaps more important is that BIM allows a central, shared virtual model to be accessible by all the integrated design team members. Each team member is able to contribute by adding ‘layers’ of information to the model, and their effects on other team members’ layers of information becomes apparent in the virtual model (Ibid.; Figure 2.12). Immediately, this facilitates the elimination of conflicts between information provided by different disciplines, a common occurrence in the fragmentary practice of

17 BCA Green Mark Assessment Criteria. Available at: <http://bca.gov.sg/GreenMark/ green_mark_criteria.html> [Accessed 21.01.2011].

57

having separate CAD files. A more profound impact it brings to the building industry is that the new paradigm of BIM workflow mirrors the integrated design paradigm (Fig 2.13), facilitating sharing and real-time collaborative working (A more detailed presentation of BIM and its benefits are presented in Appendix III). Due to its benefits and huge potentials in reinventing the construction industry, BIM is actively promoted by the Singapore government through BCA (Cheng, 2011).

BIM adoption in Singapore gathers speed only after 2008, and unfortunately KTPH did not utilize BIM as a design and documentation platform.

did not utilize BIM as a design and documentation platform. Figure 2.12 The integrated design model.

Figure 2.12 The integrated design model. Source: Krygiel and Nies, 2008, p. 37

design model. Source: Krygiel and Nies, 2008, p. 37 Figure 2.13 The traditional team model and

Figure 2.13 The traditional team model and an integrated design team model in information exchange. Source: Krygiel and Nies, 2008, p. 61

58

2.3.4.2

Integrated Design Techniques

Employing social techniques in the integrated design process facilitate behavioural change, such as (7Group et al, 2009; Busby Perkins+Will, 2007; WSIP, 2007; Roadmap, 2007) 18 :

1. Team-based meetings/charrettes/discussions to facilitate an integrated, synergistic, co-designer approach.

2. Group sessions are facilitated or guided by members with good leadership quality.

3. Good communication/dialogue/conversation/narration/negotiation.

4. Shared responsibilities among team members.

5. Shared values developed among team members.

6. Trust-building among team members.

The integrated design approach explicitly promotes the often overlooked aspect of design as a social, collective process, ‘’in which the rapport between group members can be as significant as their ideas’’ (Lawson, 2005, p. 240). Since large scale and complex healthcare projects often require a sizable building design team with support from specialists and non-design professionals e.g. clinicians, nursing leaders and operation managers, social skills and group dynamics among the team members are as crucial as their professional skills and knowledge in ensuring project success. The adoption of new mindset (Section 2.3.2) needs to be supported by appropriate social, team-based design techniques and methodologies.

In addition, some have suggested that in the creative process, group dynamics has a distinct advantage over the individual. In How Designers Think: The Design Process Demystified, Lawson (2005) described in the design of St Mary Hospital, how Tim Burton assembled a group comprising representatives from three client bodies and consultants, and over a three-day intensive design process, led the group to agree on the ‘’main

18 Some IDP literature provides very specific guides on techniques, e.g. ‘effective facilitation’ (Roadmap, 2007, p.p. 21-22). Effectiveness of these techniques may be subjected to cultural influences, and is not the focus of this dissertation.

59

heading of the brief, identified three basic design strategies and selected one for further development including rough costings’’ (Ibid., p. 241). The selected scheme became the basis for the final design.

In postulating the future roles of the designers (not limited to building designers, but particularly relevant to them) in the post-industrial society or knowledge-based society, Lawson stated that one plausible outcome is ‘’designers remain professionally qualified specialists but try to involve the users of their designs in the process’’ (Ibid., p. 30) In such a world, in which designers no longer have a monopoly of design knowledge, the participatory approach allows designers to stay relevant and engaged with the stakeholders (who may hire design and building professionals to represent them), by offering specialist skills to ‘‘identify the crucial aspects of the problem, make them explicit, and suggest alternative courses of action for comment by the non-designer participants’’ (Ibid., p. 30). The evolution of such a role for designers will be coupled with the development of new processes, e.g. IDP and new tools, e.g. building information modeling, building performance simulation, etc, as discussed in Section 2.3.3 and 2.3.4.

2.3.5 Integrated Design Products: Sustainable Healthcare Architecture

In Section 1.6.4, sustainable healthcare architecture is defined as a holistic, integrated solution that addresses the three dimensions (economic, social, environmental) in a holistic manner (Figure 1.5). In Section 2.2.4, it is further put forward that the integrated design approach is a means to realizing sustainable healthcare architecture, by integrating whole-building system design that optimizes building site layout, envelope design, system design and material selection in a holistic manner, “reducing initial cost and delivering sustained, improved performance.” (Ibid., p. 129; Bokalders and Block, 2010), community and human wellness considerations supported by evidence-based studies, as well as ecologically regenerative considerations.

60

Summarizing from the discussion so far, in the Singapore context, the relationship between sustainability opportunities and challenges, integrated design approach and sustainable healthcare architecture as an outcome may be represented by Figure 2.14.

Environmental Sustainability
Environmental
Sustainability

Design Problems

1. Disparate operational

and sustainability

Issues and

requirements Social Economic Sustainability Sustainability Team Formation and Organization Mindset Change
requirements
Social
Economic
Sustainability
Sustainability
Team Formation and
Organization
Mindset Change
Integrated Design Process
Design Process
Project Visioning
Objective Setting
Design Iteration
Design Approach
Construction &
Commissioning
Post Occupancy Feedback
Loops
Tools & Techniques

2. Integrated

Eco-Design

Biophilic Built Environment

Built environment that integrates with

natural and ecological systems

Environmental Sustainability

Environmental Sustainability Social Economic Sustainability Sustainability
Environmental
Sustainability
Social
Economic
Sustainability
Sustainability

Design Solution

3. Sustainable Healthcare

Architecture as a holistic,

integrated design

outcome/solution

Social Sustainability

Evidence-Based Wellness

Community-Stewardship

Built environment that supports integrated

healthcare and social systems

Economic Sustainability

Green Building

High-performance

Built environment as holistic,

bioclimatic system of systems

Figure 2.14 Achieving sustainable healthcare architecture through integrated design

61

2.4

Discussion:

The

Aspects

of

Integrated

Design

Process

to

be

Investigated

In Section 2.1 of this chapter, by drawing from literature, the definition of integrated design approach has been defined. It is then followed by Section 2.2, in which its relevance and benefits to the design of healthcare architecture is presented. Section 2.3 presents the essential elements of the integrated design approach (Figure 2.3). Following that, Section 2.3.3 focuses on the integrated design process, which contains the following important stages, with stage 1 to 4 being the focused study areas of this dissertation:

1.

The formation and organization of the multi-disciplinary team;

2.

The visioning process;

3.

The objective setting process;

4.

The design iteration process;

5.

Construction and commissioning process;

6.

Post occupancy feedback loops.

In summary, this chapter presents a model of the integrated design approach in theory. Most of the IDP literature acknowledged that the IDP model needs to be tailored to real- world constraints faced in practice (WSIP, 2007; IDP Roadmap, 2007). KTPH, purported

to be an example of sustainable healthcare architecture in the Singapore context, provide

a case to examine integrated design in practiced, to be compared to the theoretical

model. The comparison will be carried out in the next two chapters, starting with Chapter 3: Briefing introduction of the KTPH project, followed by its visioning, objective setting and briefing process.

62

“I posed the challenge to the AH rebuilding team: build a hospital…designed with patients unambiguously at the centre of the focus, with technology fully exploited for the benefit and convenience of patients…. It will be a hospital which is well linked… and to which the patients can be transferred seamlessly… It will be a hassle-free hospital.”

Khaw Boon Wan, then Minister of Health, Singapore “Exterior landscaped spaces on the ground of
Khaw Boon Wan,
then Minister of Health, Singapore
“Exterior landscaped spaces on the ground of
healthcare facilities have become widely referred to as
healing gardens…These spaces afford respite, and
hiatus, however brief, from the day-to-day stresses of
the hospital.”
Stephen Verderber
Chapter 3.0: Khoo Teck Puat Hospotal:
The Case Study

63

Chapter 3.0

Khoo Teck Puat Hospotal: The Case Study

Section 2.3.3 provides a theoretical model of the integrated design process. This chapter compares the visioning and objective setting process between theory and in practice by using KTPH as a reference. It begins by providing the basic background of the KTPH project, followed by an examination of the KTPH visioning and objective-setting exercises. This is done through a comprehensive study of the literature and project document, as well as through interviews with the key project team members involved. This chapter then discusses the findings.

3.1 Background

As of 2011, there are eight public hospitals in Singapore, with Khoo Teck Puat Khoo Teck Puat Hospital (KTPH) being the latest addition. The KTPH is a 550 bed acute care public hospital offering a comprehensive range of medical and health services, situated in the North to serve more than 700,000 residents in the region. (KTPH Website).

The KTPH design was developed from the winning entry selected from an international design competition. The winning design was an outcome of collaboration by a design consortium led by CPG Consultants Pte Ltd (CPG) from Singapore with many multi- disciplinary team members (Appendix IV). CPG is the firm where this dissertation author is currently working in. The author had no involvement in the KTPH project, but by way of access to personnel involved in the project and unpublished document, it facilitated the investigation of KTPH’s design process, which may be difficult for someone from outside the organization. Expressed consent was given by CPG as well as personnel interviewed in this project for the information published in this document.

3.2 KTPH’s Site Context

Situated in the northern Yishun town, the KTPH site is within walking distances to the town amenities: Yishun Town Centre, Yishun MRT Station, Yishun Bus Interchange, Yishun Town Park. It is adjacent to the existing Yishun Polyclinic, Yishun Pond, and a planned site for a future community hospital (Figure 3.1). Across the Yishun Central

64

Road one finds the SAFRA club, which caters to all Singaporean citizens who have served national service, situated in another park, the more hilly Yishun Park.

The KTPH design revolves around the concept of ‘hospital in a garden, garden in a hospital,as a response to the competition design brief which contained KTPH’s vision:

‘hospital as a healing garden’. The ‘garden in a hospital’ (Figure 3.2) refers to a central courtyard that opens on one side to the adjacent Yishun Pond, allowing visual and physical connectivity between KTPH premise and the natural setting of Yishun Pond. When viewed from the Yishun Pond’s natural setting, KTPH becomes ‘hospital in a garden’ (Figure 3.3).

Yishun Town Centre
Yishun Town Centre

Figure 3.1 KTPH layout with reference to its site context. Source: CPG Consultants Pte Ltd

65

Figure 3.2 Garden in a Hospital: Courtyard view of Khoo Teck Puat Hospital with naturalistic,

Figure 3.2 Garden in a Hospital: Courtyard view of Khoo Teck Puat Hospital with naturalistic, lush greenery. Source: CPG Consultants Pte Ltd

66

Figure 3.3 Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond

Figure 3.3 Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond Source: CPG Consultants Pte Ltd

YISHUN TOWN CENTRE, TOWN Physical PARK, MRT integration of STATION, BUS INTERCHANGE green and View
YISHUN TOWN
CENTRE, TOWN
Physical
PARK, MRT
integration of
STATION, BUS
INTERCHANGE
green and
View towards
social
Yishun Pond and
environments
Yishun Park to
engage nature
‘Garden in a
Hospital’ as
Community Space
SAFRA/
YISHUN
PARK
Public and
shuttle arrival/
HDB
drop-off
ESTATES

Figure 3.4 Integration of healthcare, social, and natural environments. Source: Design document, CPG Consultants Pte Ltd

67

KTPH’s landscaped environment not only provides the setting of ‘healing gardens’ for the well-beings of its patients and staff, it also lends itself to the Yishun community, enhancing the opportunities for social and community interaction through the spatial integration of the hospital and external landscaped environments (Figure 3.4).

In Section 3.3, KTPH’s visioning, objective setting and briefing process is be presented and compared to the visioning and objective setting in the integrated design approach presented in chapter 2.

3.3 KTPH Visioning, Objective Setting and Briefing Process

In the integrated design process, it is essential that the project establish clear vision to align team members’ mindsets, attitude (as discussed in Section 2.3.2 and 2.3.3) and commitment to align with the common purpose and shared values. This section examines the rigour and commitment by KTPH in its visioning and bar-raising objective- setting exercises; and how these have served as the navigation beacons to guide the integrated project team’s design outcome.

3.3.1 Methodologies: Focused Group Discussions and References

Focused group discussions were conducted with the KTPH project team members who were involved in the project, either individually or in groups, over one or more sessions. The discussions were made with reference to the IDP model (see Appendix IV on discussion guide), and the project document made available to this dissertation author. The use of the reference to IDP model is to ensure that the definition and mutual understanding of the ‘integrated design approach’ is as close as possible to that defined in this dissertation. The objective of the discussions and reference to the project document is to identify similarities and deviations between KTPH’s design and work processes in contrast to the IDP model. The project team members involved in the focused group discussions are shown in Table 3.1

68

Table 3.1

Key project team members involved in focus group discussions (See also Appendix II)

Role

Name

Company

AH/KTPH Hospital Planning Team

Donald Wai

Alexandra Health/ Khoo Teck Puat Hosiptal

Project Director/Architect

Lee Soo Khoong

CPG Consultants Pte Ltd

Architect

Lim Lip Chuan

CPG Consultants Pte Ltd

Architect

Jerry Ong

CPG Consultants Pte Ltd

Architect

Pauline Tan

CPG Consultants Pte Ltd

Civl & Structural Engineer

Soon Chern Yee

CPG Consultants Pte Ltd

Mechanical Engineer

Toh Yong Hua

CPG Consultants Pte Ltd

Electrical Engineer

Wong Lee Phing

CPG Consultants Pte Ltd

Green Building Consultant

Dr Lee Siew Eang

Total Building Performance Team

Green Building Consultant

Dr Nirmal Kishnani

CPG Consultants Pte Ltd

Landscape Consultant

Glenn Bontigao

Peridian Asia Pte Ltd

Quantity Surveyor

Yeo Tiong Yeow

CPG Consultants Pte Ltd

3.3.2 The Shared Visions

Back in 2004, when the decision to build the KTPH was made, the vision was first set by Minister of Health Khaw Boon Wan (Liak, 2009):

I posed the challenge to the AH rebuilding team 19 : build a hospital… designed with patients unambiguously at the centre of the focus, with technology fully exploited for the benefit and convenience of patients…. It will be a hospital which is well linked… and to which the patients can be transferred seamlessly… It will be a hassle-free hospital.

In short, it was to be patient-centric. The challenge was taken up by the KTPH management and staff, led by the visionary and determined CEO Liak Teng Lit, who had a tremendous impact in shaping the planning and operations of KTPH as well as the organizational culture (Wu, 2011, p. 106). Under his leadership, and through working together as a team in Alexandra Hospital since 2000, KTPH’s hospital planning committee (HPC), comprising eight key members representing the hospital management,

19 KTPH was taken over by the management and staff from the Alexandra Hospital, while the original Alexandra Hospital premise was transferred to JurongHealth in 2010. See History of Alexandra Hospital. Available at <http://www.alexhosp.com.sg/index.php/about_us/our_history>.

69

a representative from Ministry of Health, as well as sixteen staff-in-attendance (HPC

Minutes of meeting dated 13.01. 2010), had developed a set of shared values as presented

in Table 3.2.

The above findings validated the emphasis in the integrated design approach to have clear project vision from the start. In the case of KTPH, the CEO appeared to have played the role of a sustainability ‘champion’ (IDP Roadmap, 2007; Section 2.3.3.1) in the early stages, aligning the values and mindsets of the HPC and staff members.

Table 3.2

AH/KTPH Shared values

S/No.

 

Name

 

CEO Liak’s personal philosophy viewing “sustainability as an integral way of life,”

1.

and his vision in promoting “sustainability as a lifestyle to his staff and the community” (Liak, 2009, p. 107).

2.

CEO Liak’s belief that in “a food resource-constrained world… his hospital needed to do their part through urban agriculture” (Ibid, p. 107). As an outcome, KTPH management teamed up with retired farmers in the community to volunteer and take ownership of the roof top farm (Ibid, p. 107; Section 3.5.1)

3.

Managers keep abreast with latest trends in healthcare and management issues (Ibid,

p.

106-107).

4.

Patient-centric focus had become a shared vision among KTPH management and staff (Ibid, p. 107). This was carried out through a series of pilot projects even while operating at the Alexandra Hospital premise (DSC Case Study, 2009) . The initiatives include “shorter waiting time, access to better information, and savings on medical bills.” (Ibid., p. 2) The management tools and philosophies adopted include “the Toyota Production System (TPS) and Six Sigma to help improve the hospital’s

workflow and efficiency” (Ibid., p. 6). “AH also learned from leading organizations in various industries including hospitality, airlines, finance, and manufacturing” (Ibid.,

p.

6).

5.

Emphasis of energy efficiency and the use of natural ventilation to reduce energy consumption (Wu, 2011, p. 109).

6.

Enthusiastic staff e.g. Rosalin Tan that believes in increasing “the indigenous wild life biodiversity by introducing native species of plants in the hospital’s landscaping.” (Ibid, p. 109)

7.

A believe in hospital as a healing environment in accordance with Erik Asmussen’s seven principles: unity of form and function, polarity, metamorphosis, harmony, with nature and site, living wall, color luminosity and color perspective and dynamic equilibrium of spatial experience (Ibid, p. 110-111).

8.

Ulrich’s theory of supportive design (Ibid, p. 111), which is the domain of the evidence-based design, presented in Section 1.6.2.

70

3.3.2

Setting the Objectives

Visions need to be translated into specific project objectives for targeted actions. In an interview with Dr Lee Siew Eang 20 , who assisted KTPH in developing the project objectives, he stated that the total building performance (TBP) approach was adopted to develop the project objectives. The TBP approach was developed by Public Works Canada between 1981 and 1985, and promoted by Hartkopf and Loftness as a framework to measure building performance (Hartkopf and Loftness, 1999; Harkopf et al, 1986). It focuses on integrating six key qualities of a building, namely spatial quality, thermal comfort, acoustic quality, indoor air quality, visual quality, and building Integrity, with reference to not only economic and building performance, but human physiological, sociological, and psychological needs (Ng, 2005; Table 3.3). It is interesting that in TBP approach, considerations which contribute to social sustainability are given under the ‘Spatial quality’ criteria, with qualitative attributes such as ‘beauty’, ‘calm’, ‘excitement’, ‘view’, etc. Set up in 2000, the Centre for Total Building Performance (CTBP), a joint research centre by NUS and the Building and Construction Authority (BCA), adapted the TBP approach 21 to the Singapore context, with an aim to develop it into a design guide that is “first, an objective and comprehensive matrix, second, is user-oriented by incorporating building performance mandate agreed with users, based on building performance benchmarks obtained from existing buildings. It therefore encapsulates both a measurable, life-cycle performance indicators that is also user-driven and performance-based,” said Dr Lee in the same interview, “and after the KTPH TBP matrix had been developed, the Green Mark Platinum requirements were then slotted into the TBP matrix(Interview in January 2012).

20 Interview session was held in January 2012. Dr Lee Siew Eang is Director, Centre for Total Building Performance (CTBP). CTBP is a Joint BCA-NUS Centre for Tropical Building Research, School of Design and Environment. Dr Lee is also an Associate Professor in Department of Building, School of Design and Environment, National University of Singapore, with research interest in building performance and acoustics. 21 Other projects in Singapore developed under the TBP approach include The Urban Redevelopment Authority Centre of Singapore and the National Library Building (NLB) of Singapore.

71

Table 3.3 Organizing performance criteria for evaluating the integration of systems (Hartkoft and Loftness, 1999)

Specific

       

Performance

Criteria

Physiological Needs

Psychological Needs

Sociological Needs

Economical

Needs

 

Ergonomic

Comfort,

Habitability, calm,

excitement, view

Wayfinding, functional adjacencies

Space

Conservation

1 Spataial

handicapped

functional servicing

access,

 

No numbness,

Healthy plants, sense of warmth, individual control

   

2 Thermal

frostbite; no

Flexibility to dress with the custom

Energy

drowsiness, heat

Conservation

stroke

 
 

Air purity; no lung

Healthy plants, not closed in, stuffy; no synthetics

No irritation from neighbours, smoke, smell

Energy

Conservation

3 Air Quality

problems, no rashes, cancer

 

No hearing damage,

Quiet, soothing;

Privacy,

communication

 

4 Acoustical

music enjoyment, speech clarity

activity excitement

‘alive’

 

No glare, good task illumination, wayfinding, no fatigue

Orientation,

Status of widnow, daylit office, ‘sens of territory’

 

5 Visual

cheerfulness, calm,

Energy

intimate, spacious,

Conservation

alive

 

Fire safety; structural

 

Status, appearance,

 

6 Building

Integrity

strength and stability; weather tightness, no outgassing

Durability, sense of stability, image

quality of

construction,

‘craftsmanship’

Material/

Labour

Conservation

General

Performance

Criteria

Physical Comfort

Health

Safety

Psychological Comfort Mental Health Psychological Safety Esthetics

Privacy,

Security,

Community,

Material,

Time,

Energy,

Functional

Images/Status

Investment

By basing on the TBP approach, the KTPH HPC organized the visions into a set of thirty- one objectives, grouped under nine categories (AH tender brief for design competition, 2005). This became the design requirements for the design competition. In order to make a comparison between the TBP approach and the triple bottom line approach, these objectives are mapped against the three sustainability dimensions of economic, social and environmental/ecological, as shown in Table 3.4. While the design competition brief was not explicit, the mapping revealed that all three sustainability dimensions of economic, social and environmental were considered.

72

At this stage, the alignment of values was confined to mainly the medical professionals, with the assistance of Dr Lee and his team. The value alignment with the building professionals has not yet been carried, because they are yet to be appointed. As a public commission funded by government, it was necessary for KTPH’s project consultancy to be procured through public tender. In an interview with Donald Wai, a key member of the KTPH HPT, he said that it was decided very early on that an integrated design team was needed for the KTPH project. This decision was in part informed by their previous hospital planning experience in an attempt to relocate the Alexandra Hospital operation to another site in Jurong, and in part to meet the very tight project schedule to complete KTPH. The requirements for the formation of an integrated design team and the provision of the integrated design proposal were hence specified in the design competition. A 2-stage design competition was held, based on the quality-fee method (QFM; BCA 22 ), in which shortlisted design consortium after Stage 1 proceed to submit design and fee proposals in Stage 2. In the Stage 2 award evaluation, both the quality of the design proposal and the total consultancy fee were taken into account, based on a predetermined weightage between quality and fee.

After the conclusion of the design completion, KTPH selected the winning design submitted by the CPG-led consortium, and appointment the design consortium in May 2006. A visioning session was soon organized, to align the shared visions and to set the objectives for the whole project team. The KTPH visioning and objective setting process thus validated the IDP’s emphasis on aligning values and mindset. At this stage, the KTPH visioning and objective setting process as advocated in the IDP had been carried out in manner that suited Singapore and AH/KTPH.

The formation and organization of the multi-disciplinary building consultant team, and its working relationship with the KTPH HPC and user group is presented in the next section.

22 “QFM Framework”, BCA Website. Available at: <www.bca.gov.sg/PanelsConsultants/others/ QFM_Framework.pdf>

73

Table 3.4 Framing the sustainability focuses in KTPH’s brief for design competition (AH, 2005), with sustainability attributes added by author.

S/No.

 

KTPHs brief for design competition

Eco

Soc