Case Study For Hospital

The Practice of Integrated Design:
The Case Study of

Khoo Teck Puat Hospital, Singapore
Tan Shao Yen
31st 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.
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, 20051); 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.
Tender briefing materials by Alexandra Hospital, the forerunner of Khoo Teck Puat Hospital.
Declaration
I understand the nature of plagiarism and I am aware of the Universitys 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.
31 January 2012
Signature
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 Singapores 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
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
2.4
Integrated Design Products: Sustainable Healthcare Architecture .................................... 60

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
KTPHs Site Context ................................................................................................................. 64
3.3
KTPH Visioning, Objective Setting and Briefing Process ................................................... 68
3.3.1
Methodologies: Focused Group Discussions and References ............................................ 68
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: KTPHs Visioning, Objective Setting and Team Formation ........................... 81
Chapter 4.0: KTPHs 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
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: KTPHs 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
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: KTPHs BCA Green Mark Performance ...................................................................... 195
Appendix XIII: Thermal Comfort Outcome of KTPHs Bioclimatic and Natural Ventilation
Strategies ................................................................................................................................................... 199
Appendix XIV: Evaluating Human Wellness and Social Sustainability of KTPH .......................... 204
Appendix XV: KTPHs Environmental Stewardship .......................................................................... 209
Bibliography .............................................................................................................................................. 217
Word Count: 19,023
List of Tables
Table 1.1
Challenges related to provision of medical services
Table 1.2
Challenges Related to Healthcare Organization, Structure and Culture
Table 1.3
Evidence-based design relevant to built environment
Table 1.4
Sustainable design guides and green rating tools for healthcare facilities
Table 2.1
General factors contributing to current fragmentary state of design practice
Table 2.2
Comparison between Integrated and Conventional Design Processes
Table 2.3
Positive attitudes necessary among the integrated design team members
Table 2.4
WSIP Process Stages (2007, p.8)
Table 2.5
Core Integrated Project Team Member
Table 2.6
Additional Integrated Project Team Members
Table 2.6
IDP: Research and workshop activities for healthcare architecture
Table 3.1
Key project team members involved in focus group discussions
Table 3.2
AH/KTPH Shared values
Table 3.3
Organizing performance criteria for evaluating the integration of systems
Table 3.4
Framing the sustainability focuses in KTPHs brief for design competition
Table 3.5
AH/KTPH user work groups / departments
Table 4.1
Integrated Design Activities
Table 4.2
Integrated design considerations for faade, thermal comfort and energy usage
Table 4.3
Integrated design activities for the envelope design
Table 4.4
Integrated system design and system efficiency within systems
Table 4.5
Evidence-based evaluation for New Air (spot cooling at outdoor roof terrace)
Table 4.6
Comparison between WSIP Process Elements (2007) and KTPH Design Process
Table 4.7
Mapping KTPHs integrated design process against the IDP model with
reference to Figure 4.1 and 4.2
Table 5.1
Key Building Performance Characteristics
Table 5.2
Sustainability attributes of KTPH
Table 5.3
Integrated design attributes of KTPH
Table 5.4
Areas of study proposed for sustainability performance of KTPH
List of Figures
Figure 1.1
The complex relationships between the hospital functions
Figure 1.2
The typical compartmentalized, episodic model of care
Figure 1.3
Khoo Teck Puat Hospitals holistic Head-To-Toe Lifelong Anticipatory

Healthcare of Whole Person model
Figure 1.4
Comparisons of some green rating systems for sustainable buildings
Figure 1.5
Trajectory of environmentally responsive design
Figure 1.6
Model of sustainable healthcare architecture
Figure 2.1
Multi-disciplinary project team for healthcare project
Figure 2.2
Bryan Lawsons model of design problems or constraints
Figure 2.3
The new mental model for integrative design
Figure 2.4
Zeisels user-needs gap model
Figure 2.5
Conventional design team organization
Figure 2.6
Integrated design Team organization
Figure 2.7
Triple Bottom Line approach goal setting for a project visioning session
Figure 2.8
Integrative design process
Figure 2.9
Iterative process as proposed in Strategies for integrative building design
Figure 2.10
Iteration loops as proposed in Strategies for integrative building design
Figure 2.11
Integrative design process versus linear design process
Figure 2.12
The integrated design model
Figure 2.13
The traditional team model and an integrated design team model in information
exchange
Figure 2.14
Achieving sustainable healthcare architecture through integrated design
Figure 3.1
KTPH layout with reference to its site context
Figure 3.2
Garden in a Hospital: Courtyard view of Khoo Teck Puat Hospital with

naturalistic, lush greenery
Figure 3.3
Hospital in a Garden: View of Khoo Teck Puat Hospital across Yishun Pond
Figure 3.4
Integration of healthcare, social, and natural environments
Figure 3.5
KTPHs integrated design team organization
Figure 4.1
Integrated design process in KTPH
10
List of Figures (Contd)

Figure 4.2
The theoretical model of integrative design process
Figure 4.3
Integrated design team organization at the design competition stage
Figure 4.4
KTPH iterative process basing on the model in Strategies for integrative

building design
Figure 4.5
Iterative process model during the schematic design phase
Figure 4.6
Landscape plan showing landscaped courtyard as the heart and lung of design
Figure 4.7
Landscape schematic drawing
Figure 4.8
Sketch design for landscaped roof terrace as social space, while providing good
shading and insulation to interior spaces below
Figure 4.9
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
Figure 4.10
Landscaped roof terrace at Level 5 overlooking Level 4
Figure 4.11
Iterative process model during the schematic design phase
Figure 4.12
Bioclimatic response of KTPH: sunpath
Figure 4.13
Bioclimatic response of KTPH: prevalent wind directions
Figure 4.14
Aspect ratio of the various block
Figure 4.15
Critical review based on Environmental Design Guide for Naturally Ventilated

and Daylit Offices
Figure 4.16
Design study 1 for faade shading of the naturally ventilated ward tower
Figure 4.17
Figure 4.18
Figure 4.19
Design developed from Option 3: Fully height louvred faade and light shelf
maximizes natural ventilation and daylight
Figure 4.20
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
Figure 4.21
Interior of naturally ventilated ward: Faade system comprising louvred wall,

light shelves, and monsoon window. Natural ventilation is supplemented with
individually controlled fans
Figure 4.22
Iterative process model during the late design development (DD2) phase
Figure 4.23
Sampling points measured in wind tunnel study
11
List of Figures (Contd)

Figure 4.24
A sample of the air velocity profile across a typical ward at 1.2m height @ open,
50% open and closed conditions
Figure 4.25
A sample of the pressure coefficients chart across the faade of the subsidised
ward tower obtained as boundary conditions for the CFD study
Figure 4.26
1:20 Wind tunnel model used for the study
Figure 4.27
Subsidized ward tower faade showing solar screen to provide shade and wind
wall to induce air movement. Greenery is also integrated into the faade to
enhance visual relief
Figure 4.28
Design drawing showing location of exhaust nozzle integrated into the faade,
and the direction of throw to cool the landscaped roof terraces
Figure 4.29
CFD Simulation showing approximately 2C reduction in temperature at the

roof terrace, delivering cooling sensation to users
Figure 4.30
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
Figure 4.31
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
Figure 4.32
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
Figure 4.33
Conceptual diagramme of irrigation system and built environment as part of

natural systems
Figure 4.34
Schematic of irrigation system, drawing water from Yishun
Figure 5.1
KTPH: Post Occupancy Studies
Figure 5.2
KTPH: Sustainable Attributes mapped onto the Sustainable Healthcare

Architecture Model
Figure 5.3
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 only for competitive
advantage but also for planetary survival
healthcares 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).
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 energy2 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.).
The US Commercial Building Energy Consumption Survey conducted in 2003 found that
hospital used an average of 250,000 BTU/ft2 (approximately 788.6kW/m2), second only to food
service buildings (Singer, B. C., 2009).
2
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: KTPHs 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 Services3

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.
Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to
Improved Energy Efficiency. Lawrence Berkeley National Laboratory. pp 4.
3
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/m2 as excellent, and 348.35kWh/year/m2 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/m2 (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 lowenergy 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 Singapores 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

Culture4
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.
Singer, B. C., Tschudi, W. F., (2009). High Performance Healthcare Buildings: A Roadmap to
Improved Energy Efficiency, Lawrence Berkeley National Laboratory, p. 8.
4
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 Singapores Context
Since the introduction of the concept of the triple-bottom-line by John Elkington5, 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 Singapores
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.
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).
5
21
1.6.1 Economic Sustainability

Singapores healthcare system is ranked by World Health Organization as the best in
Asia and six globally7. 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 KTPHs 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
WHOs World Health Report in 2000 on health systems.

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).
7
8
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 Singapore9, 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.
Figure 1.2 The typical compartmentalized, episodic model of care.

Source: Liat, T. L. (2009), Planning for a Hassle Free Hospital.
Figure 1.3 Khoo Teck Puat Hospitals holistic Head-To-Toe Lifelong Anticipatory Healthcare of
Whole Person model. Source: Liat, T. L. (2009), Planning for a Hassle Free Hospital.
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 restructuring 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)
9
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 stressreducing 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 wellbeing 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 wellbeing, 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
2.
3.
The built environment should protect and support the well being of the healthcare clinicians and
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
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
6.
7.
Give all building occupants environmental comfort and control over that comfort, including heat,
light and sound. 3
Design to give patients privacy, dignity and company. 3
Verderber, 2010
McCullough, 2010
3 Lawson (2005), Evidence-Based Design for Healthcare
2
The rapidly growing body of works in EBD tends to focus on patient-benefits, staffbenefits 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
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.
10
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.
Figure 1.4 Comparisons of some green rating systems for sustainable buildings
Source: Bauer, M., Msle, P., Schwarz, M. (2010)
27
Table 1.4
Sustainable design guides and green rating tools for healthcare facilities
BREs BREEAM New Construction: Healthcare is an environmental assessment method and
1.
certification scheme for healthcare buildings in the UK (http://www.breeam.org/).

Green Guide for Health Care which provides resources for voluntary, self-certifying metric toolkit
2.
of health-based best practices (http://www.gghc.org/).

USGBCs LEED for healthcare customized the popular LEED green building rating system to
3.
support healthcare buildings 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 KTPHs 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] sustainable is defined as being at a
BCA Green Mark Scheme website [online] Available at: <http://www.bca.gov.sg/greenmark/

green_mark_buildings.html>
11
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.
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
humans 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
natural and ecological systems
Environmental
Sustainability
Social
Sustainability
Economic
Sustainability
Evidence-Based Wellness
Community-Stewardship
Built environment that supports
integrated healthcare and social systems
Green Building
High-performance
Resource-efficient
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.
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,
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).
12
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 of the Integrated Design Approach in Healthcare

Architecture
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.
1.
Factors
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 specialists 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 missedopportunities (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 integrationwe 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

Involves team members only when essential 1;
Front-loaded time and energy invested early1;
Activities become more intense towards
Intensive design process begins early at the concept
documentation stage with design coordination,
stage with charettes, workshops, etc.3
resolve conflicts 1
Engages in individual research as well as group
Linear or siloed process 1, 2, 4; limited group
iteration process, e.g. charettes, workshops, etc. 1, 2
contribution in design formulation.
Emphasis on ongoing learning and research
Preordained sequence of events
Adopt whole system thinking or whole-building
Focuses on efficient design of individual systems in
approach; allow for full optimization.1
isolation limited to constrained optimization 1
Diminish opportunity for synergies 1; poor
Seeks synergies 1
communications 4
Life cycle costing ; consider budget as a whole,

1
allowing higher cost but better design in one system

(e.g. faade) to be offset by savings from a system
Considers budget as isolated, independent systems.
(e.g. space cooling or heating).

Innovate by applying existing technologies in new
Avoid new and unproven technologies to avoid risk
ways, or incorporate group- sanctioned new
of failure or blame by others.
technologies to solve problems identified.

Preparation of two, three or more options in concept
Concept design was formulated based on functions
design alternatives, supported by energy
or image; without thorough considerations for
simulations.
environmental and social sustainability issues.
Decisions involve all the key stakeholders 1

Process continues through post-occupancy
Decisions are made by a few decision makers 1

Typically finished when construction is complete 1
References:
Busby Perkins+Will and Stantec Consulting, (2007). Roadmap for the Integrated Design Process. p. 8.
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.
1
2
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 its
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 Elements of the Integrated Design Approach for

Healthcare Architecture
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, faade, 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.
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. designers 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).
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.
14
41
Figure 2.2 Bryan Lawsons 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
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.
15
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).
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.
Figure 2.4 Zeisels 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.
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.
7Group and Reed, (2009). The Integrative Design Guide to Green Building: Redefining the Practice of Sustainability. p. 30-
31.
3
Yudelson, J., (2009). Green Building through Integrated Design. p. 46.
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
1. Team Formation
Elements
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 &
Commissioning
6. Post-occupancy
Feedback Loops
Follow through during the Construction Process.

Commission the project.
Maintain the system.
Measure performance and respond to feedback - adjust key aspects of the
system accordingly.
Whole System Integration Process (WSIP, 2007), The Institute for Market Transformation to
Sustainability, Washington.
16
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
Client or owners
representative
With expertise in operations 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
1.
With expertise in facilities management
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.
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
11.
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.
12.
Valuation/appraisal professional
5.
Planning/regulatory/code approvals agencies

reps
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.
Figure 2.5 Conventional design team organization

Source: Roadmap for the Integrated Design Process. p. 18
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 teams 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).
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.
W1
R1
W2
R2
W3
R3
W4 W5
W6
W7
R4
Figure 2.8 Integrative design process. Adapted from WSIP (2007).
50
Table 2.7
IDP: Research and workshop activities for healthcare architecture
Stage
R1: Research/
Analysis #1
W1: Workshop/
Charrette #1
Elements
Preliminary research, e.g. identify base condition, context of project, and
sustainability opportunities; project programming; preliminary climatic
studies, etc.
Visioning exercise involving all key stakeholders
Goal Setting and alignment of purpose/objectives among all participants.
Continue research, e.g. establish comparative benchmarks, envelope and
R2: Research/
Analysis #2
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
Generate or iterate concept design or early schematic design through
W2: Workshop/
Charrette #2
charrettes.
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/
Analysis #3
Iterate design at more detailed levels, optimize system designs.

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/
Charrette #3
Confirm the alignment of Client, Design, and Construction (or Cost

Estimating) team around the objectives and aspirations.
Continue refining the integration of systems.
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.
Continue to test design concepts against the Core Purpose, Design
R4: Research/
Analysis #4
Drivers, and Metrics and Benchmarks.

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
Late Schematic Design / Early Design Development.
W5: Workshop #5
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.
Pre-bid & Post Award Conferences to explain unique aspects of project
W7: Workshop #7/
Detailed review of Drawings and Specifications
Bidding &
Address non-building related sustainability issues.
Negotiations
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 2007s design development (DD) stage,
which seeks to confirm the system design, before proceeding to the design and selection
of actual building components.
Workshops/
Decisions
DD
SD
Research/Analysis
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 optimizationand 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).
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.
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 teambased 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 teams understanding 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
BCA Green Mark Assessment Criteria. Available

green_mark_criteria.html> [Accessed 21.01.2011].
17
57
at:
<http://bca.gov.sg/GreenMark/
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.
Figure 2.12 The integrated design model. Source: Krygiel and Nies, 2008, p. 37
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
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.
18
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.
Design Problems
1. Disparate operational
and sustainability
Issues and
requirements
Environmental
Sustainability
Social
Sustainability
Economic
Sustainability
Team Formation and

Organization
Mindset Change
Integrated Design Process
Project Visioning
Objective Setting
Design Iteration
Construction &
Commissioning
Post Occupancy Feedback
Loops
Tools & Techniques
Design Process
2. Integrated
Design Approach
Eco-Design
Environmental Sustainability
Design Solution
3. Sustainable Healthcare
Architecture as a holistic,
integrated design
outcome/solution
Environmental
Sustainability
Social
Sustainability
Economic
Sustainability
Social Sustainability
Economic Sustainability
Built environment that supports integrated
healthcare and social systems
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 realworld 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 hospitaldesigned 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

healthcare facilities have become widely referred to as
healing gardensThese 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 multidisciplinary 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 KTPHs 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
KTPHs 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 KTPHs 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 Ponds natural setting, KTPH becomes hospital in a
garden (Figure 3.3).
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,
lush greenery. Source: CPG Consultants Pte Ltd
66
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 towards
Yishun Pond and
Yishun Park to
engage nature
social
environments
Garden in a
Hospital as
Community Space
SAFRA/
YISHUN
PARK
Public and
shuttle arrival/
drop-off
HDB
ESTATES
Figure 3.4 Integration of healthcare, social, and natural environments.

Source: Design document, CPG Consultants Pte Ltd
67
KTPHs 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, KTPHs 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 objectivesetting exercises; and how these have served as the navigation beacons to guide the
integrated project teams 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 KTPHs 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
AH/KTPH Hospital Planning Team
Donald Wai
Project Director/Architect
Architect
Architect
Architect
Civl & Structural Engineer
Mechanical Engineer
Electrical Engineer
Green Building Consultant
Landscape Consultant
Quantity Surveyor
Lee Soo Khoong

Lim Lip Chuan
Jerry Ong
Pauline Tan
Soon Chern Yee
Toh Yong Hua
Wong Lee Phing
Dr Lee Siew Eang
Dr Nirmal Kishnani
Glenn Bontigao
Yeo Tiong Yeow
Company
Alexandra Health/
Khoo Teck Puat Hosiptal
CPG Consultants Pte Ltd
Total Building Performance Team
Peridian Asia 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 team19: 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, KTPHs hospital planning
committee (HPC), comprising eight key members representing the hospital management,
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>.
19
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
S/No.
1.
2.
3.
4.
5.
6.
7.
8.
AH/KTPH Shared values

Name
CEO Liaks personal philosophy viewing sustainability as an integral way of life,
and his vision in promoting sustainability as a lifestyle to his staff and the
community (Liak, 2009, p. 107).
CEO Liaks 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)
Managers keep abreast with latest trends in healthcare and management issues (Ibid,
p. 106-107).
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 hospitals
workflow and efficiency (Ibid., p. 6). AH also learned from leading organizations in
various industries including hospitality, airlines, finance, and manufacturing (Ibid.,
p. 6).
Emphasis of energy efficiency and the use of natural ventilation to reduce energy
consumption (Wu, 2011, p. 109).
Enthusiastic staff e.g. Rosalin Tan that believes in increasing the indigenous wild life
biodiversity by introducing native species of plants in the hospitals landscaping.
(Ibid, p. 109)
A believe in hospital as a healing environment in accordance with Erik Asmussens
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).
Ulrichs 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 approach21 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).
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.
20
71
Table 3.3
Organizing performance criteria for evaluating the integration of systems (Hartkoft
and Loftness, 1999)
Specific
Performance
Criteria
1 Spataial
2 Thermal
3 Air Quality
4 Acoustical
5 Visual
6 Building
Integrity
General
Performance
Criteria
Physiological Needs
Ergonomic Comfort,
handicapped access,
functional servicing
No numbness,
frostbite; no
drowsiness, heat
stroke
Air purity; no lung
problems, no rashes,
cancer
No hearing damage,
music enjoyment,
speech clarity
No glare, good task
illumination,
wayfinding, no
fatigue
Fire safety; structural
strength and stability;
weather tightness, no
outgassing
Physical Comfort
Health
Safety
Functional
Psychological Needs
Sociological Needs
Economical
Needs
Habitability, calm,
excitement, view
Wayfinding,
functional adjacencies
Space
Conservation
Healthy plants, sense

of warmth, individual
control
Flexibility to dress
with the custom
Energy
Conservation
No irritation from
neighbours, smoke,
smell
Energy
Conservation
Healthy plants, not

closed in, stuffy; no
synthetics
Quiet, soothing;
activity excitement
alive
Orientation,
cheerfulness, calm,
intimate, spacious,
alive
Privacy,
communication
Status of widnow,
daylit office, sens of
territory
Energy
Conservation
Durability, sense of
stability, image
Status, appearance,
quality of
construction,
craftsmanship
Material/
Labour
Conservation
Psychological
Comfort
Mental Health
Psychological Safety
Esthetics
Privacy,
Security,
Community,
Images/Status
Material,
Time,
Energy,
Investment
By basing on the TBP approach, the KTPH HPC organized the visions into a set of thirtyone 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 KTPHs 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; BCA22), 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 IDPs 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.
QFM Framework, BCA Website. Available at: <www.bca.gov.sg/PanelsConsultants/others/

QFM_Framework.pdf>
22
73
Table 3.4
Framing the sustainability focuses in KTPHs brief for design competition (AH,
2005), with sustainability attributes added by author.
S/No.
1
KTPHs brief for design competition

A hassle free hospital:
a.
Patients shall be at the centre of the focus, with technology fully exploited for
the benefit and convenience of the patients.
b.
2
It will be well-linked, and patient transfer will be seamless.

Adopt a Tricycle Model: The three thrusts of patient care, teaching &
sharing, and learning & research will mutually support one another.
A hospital for the future:
Eco
Soc
Env
a.
It is to be visually pleasing that sustains with time.
b.
Ensures ease and low cost of maintainability.
Design scalability:
a.
Designed for flexibility and adaptability.
b.
Breathability in master planning.
c.
Modular design for ease of conversion.
d.
Ability for lock-down of the hospital by zone during emergencies.
4.
Patient centric:
a.
Hassle-free processes designed for patients convenience.
b.
Engaging patients and their families as partners.
5.
c.
Safety of patients is of paramount importance.
d.
Intuitive, ease of moment for patients and visitors.
e.
Minimal movement required for patients.
Clustering of services and facilities.
Energy Efficient:
f.
6.
Technology as an Enabler: Better, faster, cheaper and safer healthcare

through digitisation, wireless technology, automation and robotics.
7.
a.
50% More energy efficient than existing hospitals.
b.
Designed to with the tropical climate in mind.
c.
Harness natural ventilation.
d.
Allow for ample overhangs.
e.
Designed for high ceilings.
f.
Make use of solar and wind power.
To achieve Green Mark Platinum Award.
g.
8
High Touch:
a.
To have a warm, cuddling feel.
b.
Environment to be calming and cheerful.
c.
Sensitive to the different age group of patient population, catering both to

the vibrant young and the mature aged.
Healing Environment:
a.
Hospital within a garden, garden within a hospital.
b.
Environment to have tranquil, restful, and healing qualities.
c.
Users are in touch with the sight, scent and sound of nature.
d.
Surrounding patients with nature, e.g. through roof garden, hanging gardens
at verandahs.
e.
Replacement ratio of 0.7 or more for greenery.
Eco = Economic Sustainability

Soc = Social/Human Wellness Sustainability
Env = Environmental/Ecological Sustainability
74
3.4
KTPH Team Formation and Organization
Based on the individual and focused group discussions conducted with the project team
members, the organization chart of the original KTPH team organization was reflected in
a hierarchical manner similar to Figure 2.5. This is due to the fact that in the building
industry that is the commonly accepted way organizational charts are drawn. When
presented with alternative diagramme of integrated design team organization (Figure
2.6), all project team members interviewed agreed that Figure 2.6 indeed better reflects
the KTPH team organization. Based on the findings of the focused group discussions, a
KTPH integrated design team organization chart (Figure 3.5) is prepared to reflect the
manner in which KTPH project team was organized. In Figure 3.5, building professionals
are shown in green, and communication among them was facilitated by the CPG
architects. The medical professionals are shown in blue, and communication among
them was facilitated by the HPT. The Core Project Team (CPT) comprises Architect,
prime consultant team, KTPH HPT, project manager and often includes landscape
architect and green consultant.23
Interior Designer
Bent Severin
Main Contractor
Hyundai
Cost Consultant/
Quantity Surveyor
CPG
Hospital Planner
RMJM Hillier
Faade
Consultant
Aurecon
Wayfinding/
Signage
Space Syntax/
Design objectives
Architect
CPG
Landscape
Architect
Peridian
Prime Consultant Team:

Mechanical, Electrical,
Structural, Civil
Engineers
CPG
Core Project
IDP Facilitator?
Green
Consultant
TBPT
Client
Ministry of Health
Representative
Project Manager
PMLink
Operator
KTPH HPT
Team
Green Mark
Authority
BCA
Regulatory
Authorities
Other government
agencies, planners,
etc
User Work Groups

/Departments
KTPH User Reps
KTPH Management
KTPH HPC
Figure 3.5 KTPHs integrated design team organization. By author, adapted from IDP Roadmap (2007).
Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
and Bontigao between Dec 2011 and Jan 2012.
23
75
Through the focused group discussions, it was revealed that while the project team
members intended to undertake design and the project in an integrated manner, they
were not aware and hence did not make use of any specific integrated design process
methodologies, such as those identified in Chapter 2.0. They were therefore very much
self-reliant, basing on past experience, as well as constantly making adjustment to the
group dynamics that was evolving and developing through working on the KTPH
project. The group dynamics began to mature as the project develops, and was stabilize
after about six months since the formal appointment of the consultants in May 2006. As
the appointment of the consultants did not make IDP a prescribed requirement, the fee
structure is similar to the traditional design approach. In other words, the fee structure
did not anticipate the rigour of the IDP. Hence throughout the project, the project team
had to adapt to the IDP practice while operating under the financial pressure of a
conventional fee structure similar to typical large scale projects in Singapore.24
The roles of the key members of the KTPH Integrated design team are discussed in 3.4.1
to 3.4.6.
3.4.1 The role of IDP Facilitator

One key difference between the KTPH integrated design team and Roadmap (2007) is
the lack of a formerly appointed champion or facilitator. While KTPHs CEO Mr Liak
Teng Lit was the defacto leader in championing sustainability issues as outlined in
Section 3.3.2, and availed himself in many of the workshops or small group meetings, he
could not be considered as an IDP champion. Understandably so, as first, a specific IDP
methodology was not consciously adopted; second, it was never a practice in Singapore
for such a role. The prevailing practice was for the architect to act as the lead consultant
to co-ordinate the efforts of the consultant team, or for the large and complex project, for
a project manager to be appointed to act on behalf of the client to oversee the project
matters. For KTPH, the project team members recounted that the integrated design
24
76
efforts do require facilitation, and through group consent that the facilitation
responsibilities were taken up and shared among the CPG architectural team, the KTPH
HPT, and the PM Link project management team. The architectural team members
focused on facilitation among the building professionals. The HPT focused on liasison
and coordination with the many user work groups and hospital departments. The
project manager team focused on work programming, people management and
scheduling which is typical of what project managers do in Singapore. The roles of the
project team members that played key roles to the integrated design process are
presented below.25
3.4.2 The role of the Architect + IDP Facilitator for Building Design
For KTPH, a 10-member architectural team was deployed by CPG, including the project
director Mr Lee Soo Khoong, architects Lim Lip Chuan, Jerry Ong and Pauline Tan who
were interviewed in focused group discussions for this dissertation. They worked in
collaboration with healthcare architectural consultant RMJM Hillier, and are supported
by medical planner Medical Planning Research International and other architectural
support staffs. Hence, team-based design was an important attribute in the architectural
design process.26
As the lead consultant, the CPG architectural team leads the building professionals in
engaging the HPT and the user representatives, as well as the building authorities. They
put in lot of efforts to facilitate inputs and requirements from different parties to be
tabled early, so as to seek opportunity for more holistic solutions. They also have to be
open to new ideas, possess good listening skills, and the willingness to learn and
develop an understanding of healthcare operation, needs and requirements of healthcare
staff, as well as the needs and requirements of patients, families and public visitors.
25
26
See Appendix IV for list of personnel.

Ibid.
77
Some of the difficulties encountered by CPG architects were the initial communication
problems with non-building professionals, e.g. even when both parties were reading the
same drawings, the interpretation and spatial understanding of clinicians and the
architect may be different. As a result:
1. Extra time spent and additional efforts were hence needed in order to ensure that
a common understanding was attained.
2. Non-building professionals did not have a full understanding of the constraints
and complexities in building design and contract implementation. Certain design
ideas that they had preferred may be constraint by other requirements, and
usually
alternative,
work-around
solutions
proposed
by
the
building
professionals are required. Intense and pro-longed user group meetings

involving co-learning were hence necessary. On the other hand, the intense
meetings had also built trust and understanding among building and medical
professionals.
3.4.3 The role of the Hospital Planning Team + IDP Facilitator for User
Groups
The 9-member hospital planning team (HPT)27 is the bridge that straddles between the
building design/project team and the hospital management represented by the Hospital
Planning Committee (HPC) and user committees. Led by the Chief Operating Officer
Chew Kwee Tiang 28 and deputized by Donald Wai, the HPT comprises clinicians,
managers and administrators (AH org chart dated 09.01.2009) who would liaise with
various departments and work groups.
The HPT initially comprises Director, Hospital Planning Chew K. T., Deputy Director Donald
Wai who oversee day-to-day hospital planning issues with focus on contract administration and
facilities management, Koh Kim Luan, Sim Siew Ngoh and Esther Yap in the early stages. Cynthia
Ong, Lye Siew Lin, Poh Puay Yong joined the project and HPT in later stages. All were involved
in specific departments based on their background. They help to bridge between the users and
consultants, were involved in NSC tenders (ID, fitment, loose furniture tenders etc) and site
coordination (Based on interview with CPG Architect Jerry Ong in Jan 2012 and AH org chart
dated 09.01.2009).
28 The role was performed by Grace Chiang up to the masterplanning stage, but later taken over
by Chew after that and through to completion and building operation.
27
78
The HPT organized a few types of meetings/workshops:
1. The monthly HPC meetings, in which inter-departmental issues, policy issues

and management issues were raised for decision making. Annotated agenda for
each HPC meeting was submitted to the participants, and key decisions were
made timely to facilitate the design process. In addition, the latest trends in
medical process, procedures and (operation) were also presented in the meetings,
and hard decisions were made decisively to incorporate some proposals into the
final design and facilities.
2. A one-week workshop was conducted once every month (User group design
workshop) during the schematic and design development stages. Altogether,
approximately fifteen such design workshops were conducted.
3. Working sessions were conducted in between the workshops involving specific
user representatives from different departments and building professionals to
follow up on issues identified in the workshops. In these working sessions,
architect, the prime consultant team (civil & structural engineer, mechanical
engineer, electrical engineer) were always represented, and selected specialist
consultant e.g. green consultant, landscape consultant, interior designer and
signage consultant were frequently present, particularly when their inputs were
required.
3.4.4 The role of the Prime Consultant Team

The Civil & Structural Engineers, Mechanical Engineers, Electrical Engineers were from
the same company as the architect, i.e. CPG Consultants Pte Ltd. This helped to reduce
potential hurdles that may impede close collaboration between the disciplines that are
from different companies, e.g. sharing of information. By being co-located in the same
building, the physical proximity between the various disciplines had also facilitated the
face-to-face interaction and design collaboration. Despite that, the focused group
discussions had also revealed that the habits developed from the entrenched linear and
fragmentary industry practices was hurdles that require persistent efforts to overcome.
79
3.4.5 The role of the Green Consultant

The CPG team was supported by its in-house green studio, CPGreen, headed by Dr
Nirmal Krishnani29 at that time during the early research stage of the design competition.
The Green Consultant role was taken up by Total Building Performance Team (TBPT)
during the design competition. They are familiar with the then new Green Mark
requirements, and provided the design team with support on climate analysis, energy
modeling, life cycle cost estimation, computational fluid dynamic (CFD) simulation, and
wind tunnel test. By utilizing these tools, TBPT worked with CPG architect and engineer
in achieving energy efficiency through integrating:
1. The bioclimatic responds of the building envelope, reducing the cooling load,
taking in considerations of view, day light and aesthetics;
2. Optimized air-conditioning and mechanical ventilation (ACMV) system, e.g. heat
recovery system, CO2 sensor, and other energy-efficient systems e.g. lighting,
transportation, etc.
Dr Lee Siew Eang who headed the TBPT recounted30 that initially, the engineers were not
comfortable providing design information to the TBPT. The trust gradually built up after
a few months, with TBPT making it a point to always return to the engineers to discuss
their findings, before they would jointly present the outcomes or proposals to the
HPT/user groups.
3.4.6 The role of User Groups

Prior and throughout the project, some twenty-plus user groups were formed e.g.
clinicians from various departments, hospital support, administration and facilities
management groups (Table 3.5). Generally, these user groups would first conduct their
own work flow studies, benchmarking practices from the best-in-class, propose system
Interview session with Dr Nirmal Krishnani held in December 2011. Dr Nirmal is currently
Senior Lecturer at National University of Singapore, as well as Chief Editor of Future Arc journal.
30 Interview session held in January 2012.
29
80
improvements, and translate these into design and spatial requirements for discussion
with the architect and the prime consultant team. These working sessions are facilitated
by the HPT and the PM Link project managers.
Table 3.5
AH/KTPH user work groups / departments (AH org chart dated 09.01.2009)
Call Centres
CD HPVF
Childcare Centre
Day Surgery
DEM
Delivery Suites & NICU
DI
Endoscopy
ICUs (Surgery & Medical)
Laboratories
Lobby & Retail
MOT
Offices
OSMH
Pharmacy
PSC/IPC
Radiotherapy
Renal Unit
SOCs
Staff Facilities
Toilets
Wards (Private, subsidized, iso)
Project Development
Construction Progress & Site Mgt
Technical
Infrastructure & IT
Archt & Struct. Design Review
Community & Grassroot Relation
AH Facilities & Migration Plan
Liason with authorities & MOH
Fire Command Centre
Yishun Pond
3.4.7 The role of the Contractor

The main contract was procured using the conventional design-bid-build method, and
hence the main contractor M/s Hyundai Engineering & Construction Co Ltd were on
board only after the award of the main tender, and was not able to participate in the
integrated design process. The project team experienced some coordination issues
during construction stage, which affirms the view that there is a disconnect between
design and construction professionals (7group and Reed, 2009, p. 10; Section 2.1).
3.5
Discussion: KTPHs Visioning, Objective Setting and Team

Formation
Even without relying on any structured integrated design methodology or guide,

through document review and focused group discussion, it was found that the KTPH
project had by and large put in place the following essential elements of the integrated
design process:
81
1. Formation of multi-disciplinary, integrated project team that comprises not only

building professionals, project manager, green design consultant, and other
building specialists, but also medical professionals, organized as user groups;
2. Robust visioning and objective setting processes were carried out, through the
application of total building performance framework, which was customized to
suit Singapores context.
With the integrated design team, the visions and objectives in place, it remains to be seen
how the integrated design process and iterations were played out. This is examined in
the next chapter.
82
This requires rethinking principles and

procedures at a higher level of generality. It
would mean changing routines and old ways
of doing things. It would require a
willingness to accept the risks that
accompany change.
David Orr
Part of the charrette process lies in knowing

that a good idea can come from anyplace.
You have to be willing to accept it. It dosent
matter where the idea comes from.
Dan Heinfeld
Chapter 4.0: KTPHs Integrated

Design Process
83
Chapter 4.0 KTPHs Integrated Design Process

This chapter examines KTPHs design process. The objective is to compare and contrast
the integrated design process in theory and in practice. Three aspects are focused on:
1. The alternation between research/analysis and workshop;

2. The iteration process in each stage, namely prelim (PD), schematic design (SD),
and design development (DD);
3. Some examples of the multi-disciplinary collaboration in the iteration process, the
role that the different professionals or experts played, and the contributions they
made.
The methodology includes, first, by mapping out the KTPHs design process, focusing
on the alternating patterns of research/analysis and workshops. It is then compared with
the IDP theoretical model, followed by a discussion. Next, examination of the iteration
processes are conducted through the various stages: design competition stage, schematic
design stage and design development stage. During the examination, the tools and
techniques employed to support integrated design decisions are highlighted. Particular
focus is drawn on the two salient features of KTPH: the biophilic site layout and massing
design that was developed in the early design stages, and the bioclimatic and naturally
ventilated subsidized ward design that was developed in the later design stages. The
examination is done through a comprehensive study of the literature and project
document available, as well as through focus group discussions with the key project
team members involved (Table 3.1).
4.1
The Process Map
Based on the focused group discussions, the integrated design process of KTPH is
mapped out in Figure 4.1. For ease of comparison, the IDP theoretical model in Figure
2.8 is reproduced in Figure 4.2. The alternating patterns of workshops and
research/analysis activities are quite similar between the KTPH process and the IDP
theoretical model, but the two starts to deviate during the schematic design stage. The
84
main activities that took place during the various stages in the process map are
summarized in Table 4.1.
Workshops
Decision
Workshops
KTPH Integrated Design Process

W2
W1
S1
DC
MP
VE1
SD
S2
VE2
DD1
DD
Prelim Masterplan SD
CD
DD2
CD
T&A
Figure 4.1 Integrated design process in KTPH. Adapted from WSIP (2007).
W1
R1
W2
R2
W3
R3
W4 W5
W6
W7
R4
Figure 4.2 The Theoretical model of integrative design process. Adapted from WSIP (2007).
4.1.1 DC: Design Competition (Prelim)

The initial research/analysis stage R1 in the theoretical IDP model (Figure 4.2) is
undertaken as the design competition stage DC in the KTPH (Figure 4.1). The design
proposal put forward by the design team (See Figure 4.3) is indeed an attempt to address
the design requirements and objectives (problems/constraints) through solution finding
(Lawson, 2005). As the design competition was conducted in two stages, feedback given
to the design team after the first presentations was given due considerations and an
improved design was put forth in the final submission. At this stage, the design concept
revolving around the notion of hospital in a garden, garden in a hospital that
85
responded to the competition design brief was established. The design integrated inputs
and basic considerations from various consultants, including (CPGs file archive):
1. Architectural and medical planning

2. Interior design
3. Wayfinding
4. Mechanical and electrical engineering design
5. Civil and structural engineering design
6. Transportation and traffic studies
7. Costing and budget
8. Total building design and green design
9. Landscape design
10. Security design
11. Acoustic design
Prime Consultant Team:
Mechanical, Electrical,
Civil, Structural Engineers,
Quantity Surveyor
CPG
Hospital Planner
RMJM Hillier
Landscape
Architect
Peridian
Architect
CPG
Green
Consultant
TBPT/CPG
Wayfinding
Space Syntax
Interior Designer
Bent Severin
Figure 4.3 Integrated design team organization at the design competition stage. Adapted from
IDP Roadmap (2007).
The design led to the successful award of the design competition and the formal
appointment of the consultant team. KTPH HPTs Wai recalled that one of the reasons
was the support of the design concept by objective data and analysis. For example,
during a design competition briefing, TBPT demonstrated by way of meteorological data
and computer simulation that by opening the courtyard towards the Yishun Pond, wind
is funneled through the courtyard to improve thermal comfort (Figure 4.12).
86
4.1.2 W1: Visioning Workshop

In Section 3.2.2, it was presented that a visioning workshop was conducted soon after the
formal appointment of consultants. This is represented as W1 in Figure 4.1. During the
1-day visioning workshop, the KTPH key representatives and the building professionals
participated in a project chartering process, in which the project visions and objectives
were thought through, debated, and chartered with all participants committing to it by
signing off the charter. Architect Ong recalled, It was emphasized to us that we are
KTPHs partners in realizing the hospitals vision.31
At this point, the project team had expanded to include both building professionals and
healthcare professionals in the Core Project Team, with other supporting building and
healthcare experts, as presented in Figure 3.5.
4.1.3 W2: Masterplanning Workshop

The visioning workshop (W1) was closely followed by a masterplanning workshop
conducted over four days, in which the programmatic requirements, the site planning,
the massing iterations were conducted through the use of sketches, simplified digital
massing studies, powerpoint slide presentations and verbal discussions. Drastic changes
were made to the programmatic arrangement, so as to better accpmmodate KTPHs
integrated care operation philosophy.32
4.1.4 MP: Schematic Design Research/Analysis/Design Process

After the masterplanning workshop, the building professionals proceeded with the
design revision and iteration process. At this stage, preliminary design studies were
conducted to validate that the objectives set out in the visioning workshop were
achievable. This stage may be considered as part of the schematic design (R2) of the
theoretical IDP model. The stage was completed with the signing off of the revised
Interview session held in Dec 2011.

31
32
87
masterplan (S1), which took place after a presentation to HPC was made and
endorsement by HPC was obtained. The signing off was more for the purpose of
recognizing work done and billing for the building professionals. In terms of design
activities, the transition from masterplan to schematic design was an on-going process,
fuzzy process.33
4.1.5 SD: Schematic Design

Issues that required a more detailed level of resolution was brought into the schematic
design (SD) stage. During this stage, the block massing, spatial organization of
departments in relation to each other, was decided. More user groups (See Section 3.4.6)
were brought in to interact with the Core Project Team (CPT; See Section 3.4). The CPT
was usually represented by the HPT, architect, mechanical engineer, electrical engineer,
with other professionals e.g. landscape and interior designers joining in as and when
required. The user groups were coordinated and facilitated by the HPT and project
manager team. The user group meetings were typically a process of co-learning, where
the users would take the building professional through their specific operational
requirements, while the building professionals would explore design options while
explaining the constraints and considerations related to building design and
construction. As recounted by Architect Ong34, during this process, KTPHs CEO Liak
Teng Lit would often attends the user group meetings for key decisions to be made,
especially pertaining to landscape and environmental sustainability issues, which are
very much his personal interests.35
4.1.6 VE1: Value Engineering Workshop

A VE workshop VE1 was conducted at the end of the schematic design (SD) stage. An
external facilitator was brought in by KTPH to facilitate the VE process. The different
34 Interview session held in Jan 2012.
35 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
33
88
options of the main building elements, e.g. link bridges, M&E design strategies, medical
service strategies, etc were presented, their pros and cons discussed, and at the end of
the VE workshop, decisions were made regarding which major design options were to
be selected.36
4.1.7 DD1 & DD2: Design Development

During the design development (DD) stage, there were two sub-stages. In DD1, internal
layouts of the individual departments were developed with the users. It was followed by
DD2, where the detailed room requirements were agreed, e.g. provision and locations of
equipment and services. Throughout the DD, the building professionals were essentially
developing the design into more specific systems and components, supported with
design tools such as calculations, simulations and metrics. Throughout this process, the
HPT and project manager would conduct interim reviews to check that the design
objectives were being met. In fact, as the design was being developed, many of the
objectives were also refined or updated. For example, as recounted by mechanical
engineer Toh Yong Hwa37, one of the KTPHs objectives was 50% more energy efficient
than existing hospitals. This was initially based on an assumption that 70% of the floor
areas were to be naturally ventilated, and the remaining 30% to be air-conditioned. As
the design developed, it was realized that even after optimization, 54% of the floor areas
were needed to be air-conditioned to meet operational requirements, and as a result the
energy saving target was agreed to be revised to 35%.38 The design development was
signed off (S2 in Figure 4.1) for the preparation of the tender bid documentation. Again,
this was more meaningful for the recognition of work done and billing; the actual design
refinement continued well into the documentation phase.39
37 Interview session held in January 2012.
38 This was nonetheless a higher target than the minimum energy saving criteria of 30% for Green
Mark Platinum.
39 Document from CPG file archive and information from interview sessions with Ong, Lim, Toh,
36
89
4.1.8 VE2: Value Engineering Workshop

A second VE workshop (VE2) was conducted in between DD1 and DD2, primarily to
decide on the faade screen design options generated. Again, an external facilitator was
appointed to facilitate the VE process. The different faade screening options were
presented and evaluated, and at the end of the VE workshop, decision regarding which
option to adopt was made. This is presented in Section 4.2.2.40
4.1.9 The Practice of Workshop/Design Charrette

From the above process map, it is observed that workshops were held frequently
throughout the project duration. CPG Architect Lim41 commented that hospital planner
RMJM-Hillier were familiar with the group design technique of design charrettes 42
(Todd, 2009), which they frequently employed in their projects. For KTPH, workshops
were practice in part to overcome the constraints of working with RMJM-Hillier as a
foreign consultant, as the physical distance of their home office in the United States
means that it is impractical to hold weekly or bi-weekly meetings, a common practice in
Singapore. Instead, a focused one-week workshop where all key stakeholders are present
to be held on a monthly basis was more effective, and it had become an established
practice with the Singapore-based project team as well, even after RMJM-Hillier had
completed their main scope of works by DD1 stage and stopped participating on a
regular basis. KTPHs Wai recounted that in between the main workshops involving key
stakeholders, many user group meetings to resolve design issues were needed. As many
of the users are clinicians and managers who had to perform duties during official hours,
it was necessary to conduct user group meetings with building professionals through
intensive mini-workshops, very often between 5pm and 10pm after working hours. Such
intense sessions were prevalent in the masterplanning and schematic design stages, but
Ibid.
Interview session held in January 2012.
42 Todd (2009) defined design charrettes in Whole Building Design Guide website as a charrette
is defined as an intensive workshop in which various stakeholders and experts are brought
together to address a particular design issue, from a single building to an entire campus,
installation, or park.
40
41
90
the intensity began to reduce in design development stage, as the design was
progressively resolved.43
4.1.10 Hospital Planning Committee Meetings that were held monthly

Not shown in the process map are the monthly HPC meetings, where the CEO, COO,
departmental heads, clinicians, nursing leaders and operation managers were
represented, as well as representative from Ministry of Health, which finances the
project. The interim solutions agreed between the user groups and the building
professionals in the workshops were presented in HPC meetings for endorsement. Issues
that could not be resolved at the workshops (e.g. inter-departmental conflicts, etc) or
opportunities for inter-departmental synergies (e.g. sharing of common resources, etc)
are identified in annotated agenda to be iterated in the HPC meetings for decision. On
the other hand, issues surfaced during the HPC meetings were also assigned to specific
user group working sessions for detailed study and/or resolution. While VE exercises
were not conducted as an on-going process as advocated in the theoretical model of IDP,
budget review was constantly conducted in the HPC meeting agenda.
While KTPHs design process map somewhat deviated from the theoretical model of the
IDP, it has so far validated such recommendations (WSIP, 2007, see Table 2.4) as:
1. Fully engage client in the design decision process (WSIP, 2007).

2. Assemble the right team (WSIP, 2007), in the case of KTPH, this includes both
building professionals and medical professionals.
3. Key attributes in team formation is teachable attitude; members come on board
not as experts but co-learners (WSIP, 2007).
4. Align team around basic aspirations, a core purpose (a hassle-free hospital), and
core values (WSIP, 2007).
43
91
5. Sustainable design brief: The core values were translated into a set of actionable
objectives based on the total building performance framework that demonstrated
sustainability considerations along the triple-bottom line (See Table 3.2).
The next section of this dissertation is to examine some examples of the iterative process
and outcomes. In the examination, the tools and techniques employed to support the
integrated design efforts are highlighted.
4.2
The Iterative Process
In Section 2.3.3.4, the model of the iterative process (Figure 2.9) proposed in Strategies
for integrative building design by van der Aa, Heiselberg and Perino (2011) was
discussed. This model, hereby known as the iterative process model (IPM) is used in this
part of the dissertation to examine selected aspects of the iterative process in the KTPH
project (Figure 4.4).
Workshops/
Decisions
DD2
DD1
SD
Research/Analysis
Figure 4.4 KTPH iterative process basing on the model in Strategies for integrative building
design (van der Aa, Heiselberg and Perino, 2011).
Text in red added for referencing with KTPH process map (Figure 4.1).
92
4.2.1 Schematic Design (SD) Stage
SD
VE1
Schematic Design
(Concept Design)
Figure 4.5 Iterative process model during the schematic design phase. Adapted from van der
Aa, Heiselberg and Perino (2011). Red annotation added for referencing with KTPH process
map (Figure 4.1).
During the schematic design stage (known as concept design phase in IPM), broad
strategies were considered, including local climate (Ibid.), programmatic zoning,
circulation strategy, green design strategy, site response, etc. A diagramme represented
this part of the iterative process is shown in Figure 4.5 (Ibid., p. 9). In the case of KTPH,
this took place in the masterplan and schematic design stages (MP and SD in Figure
4.1), soon after the masterplanning workshop.
Based on Architect Lims reflection44, he learnt from the masterplan workshop that the
main reasons for KTPHs selection of the CPG-Hillier scheme as winning entry for
further development were:
1. The scheme revolving around a garden as the heart of the scheme. This opens
up opportunities for the development of the notion of healing garden, a practice
that the KTPH management team had established since year 2000 in their
previous premise, Alexandra Hospital. The KTPH HPCs firm belief and
recurring emphasis of integrating natural environment into the healthcare
44
93
environment to harness its therapeutic properties, not only for patients, but also
for patients families, visitors, and hospital staff had since the masterplanning
workshop became ingrained into the building professionals mindset. This belief
is supported by the biophilia hypothesis (Wilson, 1984; Kellert et al, 1993) and
evidence-based studies (Ulrich, 2001; Dellinger, 2010; McCullough, 2010;
Whitehouse et al., 2001), as presented in Appendix VI.
2. The courtyard was recognized as a good orientation device to enhance way

finding, as a result contributing to KTPHs vision of a hassle-free hospital. This
is also supported by evidence-based studies (Ulrich et al, 2004), also presented in
Appendix VI. In addition, to translate the notion of patient-centric into
actionable performance criteria, KTPHs CEO Liak specifically set such challenge
for the design team: Walking distance for patient from arrival point to the
accident and emergency department shall be no more than 20m; to the clinics, no
more than 50m; to the wards, no more than 100m.
3. The layout demonstrated that good potentials for natural ventilation, which
supports one of KTPHs main objectives of high energy efficiency, tropical
design and harness natural ventilation (See Table 3.2).
The said shared values were taken up by the integrated design team. In response, design
iterations through masterplanning and schematic design, supported by evidence-based
and performance-simulated studies were focused on refining and improving the site
planning and massing layout design as shown in Table 4.1.
The design tools utilized during this stage to support the iterative process includes
climatic simulation performed by TBPT, way finding simulation performed by space
syntax45 (Figure 4.5), traffic simulation performed by CPG Transport, ETTV calculation
performed by CPG Mechanical Engineer, etc.
Space Syntax claimed to developed evidence-based methods for analysing spatial layout,
observing patterns of space use within the hospital environment and designing ward layouts and
45
94
Table 4.1
Integrated Design Activities
Professional
Built Form
Courtyard Space
Site Response
Architect
(CPG)
Adjust and provide the

revised massing layout and
site planning; provide
typical floor plans according
to programmatic
requirements
Examine the relationship of

the built form and the
courtyard space
Examine the relationship of

the built form, the courtyard
space and the Yishun Pond
Healthcare Planner
(RMJM-Hillier)
Provide options on internal

layout
Consider the view out to

courtyard for ward and staff
area
Consider the view out to

Yishun Pond for ward and
staff area
Mechanical Engineer
(CPG)
Landscape Architect
(Peridian)
Green Consultant
(TBPT)
Civil & Structural
Engineer (CPG)
Electrical Engineer
(CPG)
Wayfinding Consultant
(Space Syntax)
CPG Transport
Engineer
Provide the design team

ETTV estimate; advising on
envelope performance
Consider design of green
roof, green terraces and
vertical planting; adopt
naturalistic approach
Advise on effect of
bioclimatic response of the
built form; performed
simulation to support the
advices.
Advise design team on
structural system
Advise on preliminary
energy consumption
Proposed the use of raw water from Yishun Pond for

irrigation of landscape and outdoor washing
Investigate the effect of
daylight/shading in the
courtyard space, affecting
plant types
Investigate opportunities in
integration of landscape
design with Yushun Pond
Advise on effect of climate

on the courtyard as shaped
by built form
Consider effect of wind

movement from across
Yishun Pond
Analyze wayfinding using software simulation

Conducted traffic simulation at drop off area
Hospital Planning Team

(KTPH)
Educate design team on

operational requirements;
review design with
consultants
Review design with

consultants
KTPH Landscape
Workgroup
Examine issue of urban

farming at KTPH roof top
Share with design team

experience from AH and
preference of plant types
Review design with

consultants
The landscape drawings by Peridian Asia (Figure 4.6 to 4.10) demonstrated the design
outcome at this stage, where biophilic design took centre-stage; one in which building
and constructed landscape foster a positive connection between people and nature in
places of cultural and ecological significance and security (Guenther and Vittori, 2008,
p. 88). The biophilic approach set the stage for further and deeper collaboration between
the KTPH hospital planning team and building professionals. For example:
hospital circulation which optimise space use, wayfinding and interaction. These techniques work
by measuring the properties of spatial layouts that users perceive: lines of sight along streets and
corridors, visual fields from reception areas and nurse stations and degrees of openness and
privacy. (Healthcare at Space Syntax website). Based on Hilliers space syntax theory (Hillier,
1999), it is being promoted as a evidence-based approach (Sailer et al, 2010).
95
1. To engage in place-making, a term used by the KTPH hospital planning team in

looking out for opportunities to create landscaped corners, seating areas, terraces
(Figure 4.8 to 4.11), for patients, families, staff, and breakout spaces where
clinicians and patient/families may communicate in humane manners. This is
also presented in Section 4.2.4.
2. To enhance the thermal comfort of roof terraces (Figure 4.9 to 4.11), spot cooling
was introduced by directing the HEPA-filtered exhaust air from air-conditioned
spaces into these landscaped roof terrace areas. Mechanical Engineer Toh said
that, it effectively lowered the ambient temperature by about 2C, 46 which
contributed towards achieving a cooling sensation for users of these spaces.
Architect Ong added that to complete the integrated design, it was necessary for
the architect and landscape architect to consider the integration of the exhaust
with the faade and landscape design. As a result, waste from one system
(exhaust cooled air from air-conditioning) is hereby used as a resource to
enhance another system (outdoor landscaped social and therapeutic space).
Figure 4.6 Landscape plan showing landscaped courtyard as the heart and lung of design.
Source: Peridian Asia; CPG file archive
46
96
Figure 4.7 Landscape schematic drawing. It

shows landscaped courtyard as the heart,
addressing main entrance as arrival/foyer,
opens to basement 1 for light and ventilation,
and surrounded by landscaped terraces. The
replacement rate for the greenery is 70%.
Figure 4.8 Sketch design for landscaped roof terrace as social space, while providing good
shading, insulation to interior spaces below, and integrated with spot cooling by recovering
cooled temperature from exhaust air. Source: Peridian Asia; CPG file archive
97
Figure 4.9 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. Source: Peridian Asia; CPG file archive
Figure 4.10 Landscaped roof terrace at Level 5 overlooking Level 4.

Source: Peridian Asia; CPG file archive
98
4.2.2 The Design Development (DD1) Stage
DD1
VE2
Design Development
(System Design)
Figure 4.11 Iterative process model during the schematic design phase.
Adapted from van der Aa, Heiselberg and Perino (2011)
As the design process enters the design development stage (DD1; known as system
design phase in IPM; Figure 4.11), van der Aa, Heiselberg and Perino proposed that
integration of system design be carried out. For KTPH at this stage, block layout and
floor plans reflecting each departments operational work flow were progressively being
iterated and agreed. Specific architectural and technical solutions were proposed,
supported by design calculations and simulations. During this phase, the design team
members were also seeking opportunity for integration of system design.
The bioclimatic response of the KTPH site planning is shown in Figures 4.12 (sun path)
and 4.13 (prevalent wind directions). The orientation of the blocks, as constraint by the
site boundary and the primary objective of orientating the courtyard towards the Yishun
Pond, is less than ideal as the private wards tower (P) is directly exposed to east and
west sun, while the subsidized ward (S) and the specialist outpatient clinics blocks (SOC)
are exposed to east and west sun at an angle, and the project team noted that careful
envelope design was required to address that. On the other hand, as stated in Section
4.1.1, the site orientation does facilitate air movement from the prevalent wind directions
through the courtyard. One other consideration is to place the naturally ventilated
subsidized ward tower furthest away from the main road as it is most vulnerable to
traffic noise pollution.
99
Stereographic Diagram
345
Location: SINGAPORE, SGP
15
330
30
10
315
45
20
30
300
60
40
1st Jul
50
1st Jun
1st Aug
75
60
285
1st May
S70
1st Sep
80
SOC
1st Apr
270
90
1st Oct
SOC
1st Mar
SOC
255
1st Feb
17
16
18
1st Jan
15
13
14
12
11
10
1st Nov
105
9
8
1st Dec
19
240
120
225
135
NV Ward Outline
210
150
Overall Massing Outline
195
165
180
Figure 4.12 Bioclimatic response of KTPH: sunpath

Sunpath generated using Autodesk Ecotect with weather data from EnergyPlus website.
Pre vailing W inds

W ind Fre que ncy (H rs)
345
Location: SINGAPORE, SGP (1.4, 104.0)

Date: 1st January - 31st December
Time: 00:00 - 24:00
Weather Tool
NORTH
50 km/ h
hrs
15
381+
330
30
342
304
40 km/ h
315
266
45
228
190
30 km/ h
152
300
60
114
76
20 km/ h
<38
285
75
10 km/ h
SOC
WEST
EAST
SOC
SOC
255
105
P
240
120
225
NV Ward Outline
Overall Massing Outline
135
210
150
195
165
SOUTH
Figure 4.13 Bioclimatic response of KTPH: prevalent wind directions

Sunpath generated using Autodesk Ecotect with weather data from EnergyPlus website.
100
In addition, the breeze across the open pond park land area would also be more
beneficial to the naturally ventilated wards than the air-conditioned private wards.
In the design, the project team had also taken into account the aspect ratio of the block
massing in response to the ventilation mode (Figure 4.14). To facilitate natural
ventilation, shallow plans were adopted for the naturally ventilated subsidized ward
tower. The air-conditioned private ward tower and the specialist outpatient clinics block
were designed with deeper plans to reduce the envelope-to-space ratio, so as to conserve
energy by minimizing heat gain through thermal exchange of the envelope. A critical
review based on BREs environmental design guidelines (Rennie and Parand, 1998)
revealed that the naturally ventilated ward design have satisfied the environmental
design guidelines (Figure 4.15). For example, the room depth to height ratio of 2.5 or less
was achieved for natural ventilation. This does mean that the day light penetration of
room depth to height ratio of 2.0 was marginally sub-standard; hence the integrated
design again came into play. Architect Ong recounted that when light shelf was
considered, daylight simulation was performed by TBPT to validate the improvement in
daylight distribution. After that, to meet the lighting performance criteria of 550lux,
M&E engineer Toh Yong Hua designed artificial lighting linked to photo-sensors. The
artificial lighting will only be turned on when the photo-sensors detect that the daylight
Naturally Ventilated
Subsidized Wards
70m
30m
20m
75m
40m
40+3m
35m
75m
Figure 4.14 Aspect ratio of the various block. Source of base drawing: CPG Consultants Pte Ltd.
101
0.8m 0.7m
0.4m
4.2m
2.7m
0.6m
Light
Shelf
External
shading
Wind wall
H = 3.3m
2H = 7.6m
H = 3.3m
2.5H = 8.25m
Figure 4.15 Critical review based on Environmental Design Guide for Naturally Ventilated and
Daylit Offices (Rennie and Parand, 1998). Source of base drawing: CPG Consultants Pte Ltd.
level has fallen below 550lux. As a result, energy is consumed only when it is absolutely
necessary to meet the performance required. For air-conditioned areas, this also resulted
in a reduction of heat load attributable to artificial lighting.
Toh added that for the air-conditioned single-room private wards, local control is
provided to the patients. For patients who prefer natural ventilation, the windows are
openable. When the windows are opened, the micro-switch at the window would
immediately deactivate the air-conditioning system, hence reducing chill water usage,
conserving both energy and water usages. The air-conditioning system design must
therefore incorporate control systems that dynamically monitor the demand. To match
demand with supply as closely as possible, variable flow chilled water system is used.
The demonstration of integrated design effort at this stage is most clearly seen in the
integrated envelope design solution to balance the considerations for view, day lighting
and thermal comfort by examining influencing factors holistically as shown in Table 4.2.
102
Table 4.2
Integrated design considerations for faade, thermal comfort and energy usage
Naturally ventilated areas
Air-conditioned areas
View
Daylight level
Daylight distribution
Shading from direct solar penetration
Tint on glazing to achieve glare reduction
Minimizing heat gain through external envelope,
i.e. ETTV (a composite value measure in W/m2 that
takes into account conduction and radiation)
Thermal comfort based on the adaptive model
Air movement through CFD and wind tunnel
study; introduce Wind Wall.
Rain protection
View
Daylight level
Daylight distribution
Shading from direct solar penetration
Shading coefficient of glazing materials
Minimizing heat gain through external envelope,
i.e. ETTV (a composite value measure in W/m2 that
takes into account conduction and radiation)
Thermal comfort based on the adaptive model
-
The role and activities played by the various team members are summarized in Table 4.3.
Each design iteration of the faade system (by architect; Figure 4.16 to 4.21) were
analyzed in terms of its ETTV performance (by mechanical engineer), daylight
performance and natural ventilation performance (by green consultant), construction
cost estimate (by quantity surveyor), and estimation of life-cycle electrical consumption
as an outcome to the resultant cooling load (by electrical engineer). These factors of
considerations were deliberated at the second value engineering workshop (VE2),
allowing an informed decision to be made, balancing the considerations for view,
daylight, natural ventilation, shading coefficient, aesthetic, capital expenditure, and lifecycle cost, etc. In a nutshell, the building envelope, daylighting/artificial lighting,
ventilation strategy, view, rain protection, and aesthetics were performing as a system
and an integrated whole (Ong, interview sessions in Jan 2012).
Table 4.3
Integrated design activities for the envelope design
Professional
Architect (CPG) +
Faade Consultant (Aurecon)
Mechanical Engineer (CPG)
Green Consultant (TBPT)
Electrical Engineer (CPG)

Civil & Structural Engineer (CPG)
Quantity Surveyor (CPG)
Built Form
Considered various design iterations of shading device, including
aesthetics.
Make design adjustment based on consultants input.
Provide the design team ETTV estimate for each iteration of shading
device design option.
Provide advice on the envelope performance to be targeted.
Provide advice passive and active design strategy.
Performed simulation iterations to support the advices.
Performed daylight simulations.
Performed CFD simulations and wind tunnel tests.
Propose design improvement to enhance the performance of the
building envelope.
Provide advice on estimation of energy consumption
Provide life cycle cost estimation, based on energy consumption.
Provide advice on support system for shading devices.
Provide cost estimate for each design iteation.
103
Figure 4.16 Design study 1 for faade shading of the naturally ventilated ward tower.
Source of drawing: CPG Consultants Pte Ltd.
Figure 4.17 Design study 2 for faade shading of the naturally ventilated ward tower.
Source of drawing: CPG Consultants Pte Ltd.
104
Figure 4.18 Design study 3 for faade shading of the naturally ventilated ward tower. This
design was selected to maximize NV and lighting. Source of drawing: CPG Consultants Pte Ltd.
Figure 4.19 Design developed from Option 3: Fully height louvred faade and light shelf
maximizes natural ventilation and daylight. Source of drawing: CPG Consultants Pte Ltd.
105
Figure 4.20 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. Source of drawing: CPG Consultants Pte Ltd.
Figure 4.21 Interior of naturally ventilated ward: Faade system comprising louvred wall, light
shelves, and monsoon window. Natural ventilation is supplemented with individually
controlled fans. Source of image: CPG Consultants Pte Ltd.
106
4.2.3 The Component Design (DD2) Stage
DD2
S2
Figure 4.22 Iterative process model during the late design development (DD2) phase.
Adapted from van der Aa, Heiselberg and Perino (2011)
In the late design development stage (DD2; known as component design phase in IPM;
Figure 4.22), van der Aa, Heiselberg and Perino proposed that component design and
selection are carried out to develop and complete the system design.
For KTPH, examples of the integrated design activities at this phase are selected to
demonstrate system thinking and system efficiency, as summarized in Table 4.4, and
presented in Section 4.2.3.1 to 4.2.3.4.
Table 4.4
Integrated system design and system efficiency within systems

Categories
1. Interdependency of faade
system, thermal comfort system,
daylight/lighting system
2. Interdependency of airconditioned system and natural
ventilation system
3. Interdependency of built
environment and natural systems
4. Resource efficiency within each
M&E system design
Description
Study of air movement leading to the integration of wind wall on
the faade of the naturally ventilated subsidized ward tower. This
is to refine the faade system proposed in DD1 stage (Section
4.2.2). This is briefly presented in Section 4.2.3.1
To support the idea of enhancing the thermal comfort of roof
terraces, to facilitate its use as outdoor social space (Section 4.2.1),
detailed design of the spot cooling design was tested using CFD
simulation. This is briefly presented in 4.2.3.2
By discharging rainwater into Ponggol Pond, and utilizing
Punggol Pond water for irrigation and outdoor washing to
consume the use of portable water, reducing carbon footprint in
the process. This is briefly presented in 4.2.3.3
Finally, energy-efficient system and resource-efficient system
design is carried out for M&E engineering design. This is briefly
presented in 4.2.3.4
107
4.2.3.1 Wind Wall at the Naturally Ventilated Subsized Ward Tower

Architect Ong recounted that during this stage, for the naturally ventilated subsidized
ward tower, computational fluid dynamic (CFD) and wind tunnel studies were
conducted to study the air movement to ensure that it functions well. Through the study,
it was found that air speed from the southern prevalent wind was less than the desirable
0.6m/s most of the time47, and TBPT proposed the use of wind wall as a device to
increase wind pressure on the faade, hence inducing the wind into the interior. A
second round of CFD and wind tunnel study was conducted to ensure that the wind
wall performs to expectation (Figure 4.23 to 4.27).
Figure 4.23 Sampling points measured in wind tunnel study. Source: TBPT; CPG file archive
Relative air speed of 0.6m/s was targeted to result in the thermal sensation of about 2C drop in
temperature (Butcher, 2005).
47
108
Figure 4.24 A sample of the air velocity profile across a typical ward at 1.2m height @ open, 50%
open and closed conditions. Source: TBPT; CPG file archive.
Figure 4.25 A sample of the pressure coefficients chart across the faade of the subsidised ward
tower obtained as boundary conditions for the CFD study. Source: TBPT; CPG file archive
109
Figure 4.26 1:20 Wind tunnel model used for the study. Source: TBPT; CPG file archive
Figure 4.27 Subsidized ward tower faade showing solar screen to provide shade and wind
wall to induce air movement. Greenery is also integrated into the faade to enhance visual relief.
4.2.3.2 Detailed Deisgn of Spot Cooling at Roof Terraces: New Air

To enhance the thermal comfort of landscaped roof terraces (Section 4.2.1), spot cooling
was introduced by directing the cooled exhaust air from operating theatres into these
roof terrace spaces. Dilution, high-efficiency particulate air (HEPA) filter and UV
sterilization were techniques used to ensure infection control. Mechanical Engineer Toh
affectionately named the system New Air, and CFD (Figure 4.28 to Figure 4.32) and
110
evidence-based evaluation (Table 4.4) was performed at this stage to research the
outcome before its implementation. The adaptive re-use of waste from one system
(exhaust air from air-conditioned operating theatre) to enhance another system
(naturally ventilated outdoor landscaped social space) demonstrates inter-dependency of
systems (Toh, interview sessions in Jan 2012).
Figure 4.28 Design drawing showing location of exhaust nozel integrated into the faade, and
the direction of throw to cool the landscaped roof terraces. Source: CPG Consultants Pte Ltd
Figure 4.29 CFD Simulation showing approximately 2C reduction in temperature at the roof
terrace, delivering cooling sensation to users. Source: CPG Consultants Pte Ltd
111
Figure 4.30 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. Source: CPG Consultants Pte Ltd
50 m
40 m
30 m
@L4 Roof Garden
@L1 Lobby
20 m
10 m
5m
0m
57dBA
43dBA
37dBA
31dBA
27dBA
25dBA
23dBA
Figure 4.31 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. Source: CPG Consultants Pte Ltd
112
Figure 4.32 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.
Table 4.5 Evidence-based evaluation for New Air (spot cooling at outdoor roof terrace). Source:
Considerations
Reference
1.
2.
3.
4.
Standards
complied
with
5.
6.
7.
8.
9.
Measures
implemented
Guidelines for Design and Construction of Healthcare Facilities, AIA 2006

HVAC Design Manual or Hospitals and Clinics, ASHRAE 2003
HTM 2025
Guidelines for Environmental Infection Control in Health-Care Facilities, CDC Atlanta
2003
Guideline for Preventing the Transmission of Tuberculosis in Health-Care Settings,
CDC
Meeting JCAHOs Infection Control Requirements, JCI 2004
EPA Technical Brief on Biological Inactivation Efficiency In-Duct UVC Devices
CP13 Mechanical Ventilation and Air-conditioning in Buildings 1999
Guidelines for Good Indoor Air Quality in Office Premises, NEA 1996
1. Sufficient DiLUTION of Exhaust Air can be achieved through mixing with outdoor air.
Reduction of ambient temperature at 2 to 4
be achieved.
2. STERIL-AIRE UVC in-duct emitters for INFECTION CONTROL provide germicidal
irradiation with periodical monitoring of bacterial counts and fungal counts according
to NEA guidelines on Indoor Air Quality(IAQ) by accredited Laboratory. The Emitters
are Environmental Protection Agency(EPA) tested proven industrial-grade air
sterilizing system.
3. The application exceeds the CDC guidelines, HTM and other design codes for
treatment of OT exhaust air.
4. All OT exhaust fans are coupled with in-out Silencers for acoustic treatment
5. All UVC emitter performance are tracked by BMS for real-time monitoring(round the
clock) using radiometers linked to alarm and fault reporting
6. Due to UVC failure, the application can be suspended as and when required for
individual OT or multiple OT exhaust by diverting the nozzle diffusers to the sky
7. The complete application can also be suspended under pandemic outbreak situation.
113
4.2.3.3 Water Efficient Landscaping Irrigation System

The rainwater collected within the KTPH site is discharged into Yishun Pond, adjacent to
the site. The raw water (non-portable) from Yishun Pond is then used for landscape
irrigation and floor washing in KTPH, to reduce consumption on potable water48, hence
reducing carbon footprint. Essentially, the rainwater resource and irrigation needs of the
KTPH site were seen as part of the larger hydrological cycle. Newater, water recycled
from sewage was used as a backup water source for the irrigation system (See Figure
4.33 and 4.34). In the system, efficient drip irrigation system and rain sensors were
utilized to reduce wastage (Toh, interview sessions in Jan 2012).
Precipitation
Building-Integrated
Natural Environment
(Biophillic Architecture)
Rainwater
treatment
Built
Environment
Reduced Carbon
Footprint
Rainwater Runoff
/Discharge
Rainwater
Reuse
Evapo-transpiration
Pond
water source with
New water source as
backup
Figure 4.33 Conceptual diagramme of irrigation system and built environment as part of
natural systems. Source: CPG Consultants Pte Ltd
Treatment and pumping of portable water consumes energy. By utilizing and replenishing raw
water at site, unnecessary energy consumption is eliminated.
48
114
Figure 4.34 Schematic of irrigation system, drawing water from Yishun.

4.2.3.4 Resource-Efficient M&E System Design

Toh commented that for mechanical & electrical engineering (M&E) design, it would be
crucial at this stage to select the most efficient M&E equipment available in the market,
and checking with manufacturers that the equipment performs well as a system (See
Appendix VII). The M&E design was supported by:
1. Energy modeling was performed by the green consultant with simulation

parameters supplied by architect, mechanical and electrical engineers.
2. Based on the ETTV target agreed by the project team, architects confirmed the
window opening size and glazing material selection based on the appropriate
glazing properties e,g, shading coefficient, light transmittance, low-emissivity,
etc.
At this stage, green rating tools such as Green Mark metric were used to validate and
fine-tune green design. The measures adopted in KTPH are shown in Appendix VII to X.
115
4.3
Discussion: KTPHs Integrated Design and Iterative Process
This chapter highlighted some examples of close collaboration between the medical
professionals and building professionals in the KTPH project. The design process in fact
continued to develop during the construction phase (See Appendix X), which is not the
focus in this dissertation. Through the examination of KTPHs integrated design and
iterative process, it showed that even without having the benefits of referring to
structured IDP methodologies, by using a IDP methodology that was developed inhouse and customized by the project team to suit KTPHs unique requirements, many of
the IDP elements and practice measures advocated had emerged and were practiced in
the KTPH design process. The evaluation matrices that summarize the comparison
between the IDP model and KTPH are shown in Table 4.5 and 4.6, with reference to the
Table 4.6
Comparison between WSIP Process Elements (2007) and KTPH Design Process
Stage
1. Team
Essential Elements in WSIP Process Stages (2007, p.8)
Practiced in
KTPH IDP
Yes
Yes
Formation
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
Yes
Yes
Yes
Yes

Key attributes in objective setting is to involve all participants,
including the main financial decision maker, not unempowered
Yes
representative. Also, identify champions for the objectives and

issues.
4. Design Iteration
Yes
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
Yes
among team with all participants, including the main financial

decision maker.
5. Construction &
Commissioning
6. Post-occupancy
Feedback Loops
Not included in this study
NA
Not included in this study
NA
116
Table 4.7
Mapping KTPHs integrated design process against the IDP model with reference to
Figure 4.1 and 4.2.
WSIP (2007)
Stages
KTPH IDP Stages
Comment
R1 in Fig 4.2
DC in Figure 4.1:
Design Competition
W1 in Fig 4.2
W1 in Figure 4.1: Visioning Workshop
W2 in Figure 4.1: Masterplan Workshop
R2 and W2
in Fig 4.2
MP in Figure 4.1: Masterplan Workshop

S1 in Figure 4.1: Workshop + Sign off
masterplan
R3 and W3
in Fig 4.2
SD in Figure 4.1: Schematic Design

VE1 in Figure 4.1: Value engineering
workshop 1
R4 and W4
in Fig 4.2
DD1 in Figure 4.1: Schematic Design

VE2 in Figure 4.1: Value engineering
workshop 1
DD2
W5
S2
W6
CD and Construction Stage
Research in KTPH design competition was

done in an integrated building design team,
but without involve-ment of users e.g.
clinicians
This validates the IDP model for visioning.
Masterplan is not an expressed stage in IDP
model. This can be considered as part of SD
in IDP model.
This validates the IDP model for
research/workshop.
While KTPHs iterative process is more
prolonged, it is due to the complexity of the
hospital typology. This more or less validates
the IDP model for research/workshop.
Design process in practice is more fuzzy, and
do not progress in distinct stages as in theory
(Lawson, 2005). DD1 in KTPH may indeed
be considered as an extended SD. This,
together with a second VE workshop
appears to validates the IDP model.
Iterative design process in KTPH continued
into DD2. This reflects the complexity of a
hospital typology.
The decision workshop to confirm the
outcome of DD in both IDP model and
KTPH again validates the IDP model.
KTPHs integrated design process in fact
extended beyond DD, into the construction
stage, exploring other opportunities (See
Appendix IX).
process map of IDP model (Figure 4.2) and KTPH process map (Figure 4.1).
In Section 2.3.4.2, the importance of group dynamics supported by appropriate social,

team-based design techniques and methodologies has been presented. This is validated
by the experiences and reflections by the project team members who had participated in
the KTPH integrated design process. In reflection, however, there are also lessons to be
learnt. In the next concluding chapter, the KTPH built environment as an outcome of the
integrated design process, and purported as a sustainable healthcare architecture, is
evaluated with reference to various post-occupancy studies. It is followed by a
discussion on lessons learnt from the research so far, and further recommendations.
117
The true value of an integrated process is an

improved building with less waste in its
production and operation. These better building
improvements include reduced operating costs,
rightsizing, the improved health and productivity
of the staff, and enhanced patient experience.
It is critical that we begin to move beyond green

buildings, even current generation of green
building tools, and embrace the concept of living
buildings or even restorative buildings.
Bob Berkebile
Chapter 5.0: Conclusion
118
Chapter 5.0 Conclusion

Following the last chapter, in which the KTPH iteration process was presented, this
chapter briefly evaluates the KTPH built environment as an outcome of the integrated
design process, i.e. as a sustainable healthcare architecture. It is followed by a
presentation of the lessons learnt from the research on the practice of integrated design
in KTPH, which provides the materials for a discussion. Following the discussion, a few
recommendations are made on future research directions.
5.1
KTPH: Sustainable Healthcare Architecture in Singapore
The evaluation of KTPH as a sustainable healthcare architecture is carried out based on

various post-occupancy studies (Table 5.1), and is presented in Section 5.1.1 to 5.1.4.
Table 5.1
KTPH: Post Occupancy Studies
S/No.
1.
2.
3.
Description
Preliminary energy consumption study conducted by CPG Mechanical Engineer Toh
Yong Hua.
Sng, P. L. (2011). In What Way Can Green Building Contribute to Human Wellness in
the Singapore Context? M Arch. National University of Singapore.
Wu, Z. (2011). Evaluation of a Sustainable Hospital Design Based on Its Environmental
and Social Outcomes. MSc. Cornell University.
5.1.1 KTPH as a Green Building

KTPH was certified as a BCA Greenmark Platinum building (see Appendix XI) in 2010,
the highest recognition as a high performance, resource-efficient building in the
Singapore and tropical context (See Appendix VII to X). Its key building performance
characteristics are summarized in Table 4.7. Two positive observations of its
performance as a green building are:
1. A post-occupancy survey (Sng, 2011) have found that natural ventilation is a

viable strategy for both in-patients and nursing staff (See Appendix XIII).
2. BCA Green Mark requires that the actual building performance be submitted one
year after occupation, to confirm that the design measures are implemented. In
119
preparation for the submission, CPG Mechanical Engineer Toh found that actual
metered energy consumption is in fact lower than energy modeling performed
during the design, with an average savings of 46.6% between July 2010 and Sep
2011. As of this writing, the data is still being analyzed.
Table 5.1
Key Building Performance Characteristics

(Guenther and Vittori, 2008, p. 173; CPG Green Mark submission document)
Category
Site
Energy
Description
Water
Indoor
Environmental
Quality
Renewable
Energy
Innovation
Extensive landscaping contributes to reducing heat island effets.

Naturally ventilated subsidized ward benefits from breeze from Yishun Pond.
Extensive tree planting.
Extensive use of natural ventilation (36% of floor area).
Naturally ventilated external corridor reduces space cooling demands.
Energy-efficient conventional M&E system design, resulting in energy reduction of
36.4% compared to baseline reference model.
Shading device on the faade to reduce solar heat gain.
Courtyard extends to basement to provide natural ventilation and daylight.
Yishun Pond landscape and social amenities improved. Rainwater runoff from site is
discharge into Yishun Pond in compliance with sustainable drainage design.
Raw water from Yishun Pond is used for irrigation and outdoor washing.
Water-efficient fittings are used.
Naturally ventilated subsized ward tower is designed with shallow plan to maximize
cross ventilation.
Acoustic comfort was designed to meet performance objectives of stress-reducing
environment.
Indoor air is treated with UVC and anti-bacteria measures to meet infection control
objectives.
Naturally ventilated corridor engages landscape courtyard.
Lightshelves to maximize daylight in the interior.
Shading device on the faade to reduce solar heat gain.
Wind wall to improve natural ventilation.
Solar thermal hot water system generating 21,000litres/day to fully meet hospital
needs.
130kWp photovoltaic system
Self-sustaining ecological pond.
Achieve spot cooling for outdoor landscape roof terrace social spaces by making use
of HEPA-filtered exhaust air from operating theatres.
Dual refuse chutes for separation of recyclable waste.
Siphonic rainwater discharge system to reduce pipe size, hence reduce space wastage,
as well as to reduce noise.
Automatic waste and soft linen collection systems.
Auto tube cleaning system was used to reduce consumption by approximately 20%.
Composting machine was used to process food waste into fertilizer for roof and food
gardens.
120
5.1.2 KTPH: Embracing Social Sustainability

Post occupancy survey by Wu found that its natural environment has been the most
well-liked feature (Wu, 2011; see also Appendix XIV). This has directly or indirectly
contributed to the positive outcome of KTPH being a desirable social environment
(Ibid.), enhancing wellbeing for patients, their friends and families, visitors, public, as
well as healthcare workers.
Sng also found that these wellness dimensions of World Health Organizations Quality
of Life (WHOQOL) are in fact missing from BCA Green Mark rating system (Ibid., p.
75). In focusing on technical performance of the built environment, Green Mark aims to
address the issues of reduced consumption of energy and resources, but it does not
address social and ecological dimensions of sustainability. Such are perhaps not the
current purpose of Green Mark rating system; but it also indicates that the objectivessetting of social and ecological dimensions would have to be generated independently
from the Green Mark rating system, as has been demonstrated through the visioning and
objectives-setting efforts in the KTPH Project using the TBP framework (Section 3.3).
5.1.3 KTPH: Embracing Environmental Sustainability

By adopting an integrated approach in site planning, connecting the KTPHs
environment with Ponggol Pond and the Yishun natural and community contexts, the
design has opened up opportunities for community and environmental stewardship for
KTPH, as follows:
1. Maximizing opportunities in creating a biophilic built environment (Appendix

VI).
2. Integrating with Yishun Pond environmentally and socially (Appendix XI & XV).
3. Fostering biodiversity, particularly an ecosystem that nurtures local butterflies
(Appendix XV).
121
KTPH management team has demonstrated track records and commitment in their
previous premise (AH) in fostering a biophilic environment and butterfly biodiversity
(See Appendix XV). By embracing the same approach in the much higher-density 3.5Ha
KTPH site that is one-third the size of the 13.5 Ha AH site, and having operated for
slightly more than a year, the outcome is still being monitored. What is interesting here
is that the design and operation of KTPH appears to move in a direction towards
environmental restoration/regeneration (Kellert, 2004; Birkeland, 2002; Reed and Malin,
2005; see Section 1.6.3).
5.1.4 KTPH: Mapping the Attributes of Sustainable Healthcare

Architecture and Integrated Design Approach
Summarizing from Section 5.1.1 to 5.1.3, ten sustainable attributes are identifiable in
KTPH, as summarized in Table 5.2. These attributes are mapped onto the Sustainable
Healthcare Architecture Model proposed in Section 2.3.5, as shown in Figure 5.1. This
diagramme put forth the case of KTPH as a positive example of sustainable healthcare
architecture in the Singapore context.
Table 5.2
Sustainability attributes of KTPH
S/No.
1
Attributes
Green building reduces carbon footprint due to less non-renewable resources
consumed (Section 5.1.1; Appendix VII, VIII, IX, X, and XII)
Staff morale and productivity improves due to better physiological,

psychological and sociological well-beings (Section 5.1.2; Appendix XIV)
High-performance green building reduces expenditure on utilities, resulting

in life cycle savings (Section 5.1.1; Appendix VII, VIII, IX, X, and XII)
Eco
Soc
Patient well-being, faster recovery (Section 1.6.2; Appendix VI and XIV)
Hospital clinician/staff well-being (Section 1.6.2; Appendix VI and XIV)
Family/visitor/public well-being (Section 1.6.2; Appendix V and XIV)
Community participation through community stewardship programmes

(Section 5.1.2; Appendix XIV and XV)
Biophilic environment, creating symbiotic relationship between human and

nature (Section 1.6.3; Appendix VI)
Ecological integration between KTPH and Yunshun Pond (Section 1.6.3;

Appendix VI, XI and XV)
10
Fostering biodiversity through environmental stewardship (Section 1.6.3;

Appendix VI and XV)

122
Env
Reduced Carbon Footprint

Staff Morale & Productivity
Life Cycle Savings
Patient Well-being
Hospital Staff Well-being
Family/Visitor Well-being
Community Participation
Biophilic Environment
Ecological Integration
Fostering Biodiversity
Eco-Design
Environmental Sustainability
Social Sustainability
Built environment that supports integrated
healthcare and social systems
Green Building
High-performance
Built environment as holistic,
bioclimatic system of systems
Figure 5.1 KTPH: Sustainable Attributes mapped onto the Sustainable Healthcare Architecture Model.
Keeler and Burke have stated, Integrated building design is the practice of designing
sustainably (2009). The evaluation in this section validates that the integration design
approach is highly relevant and practicable to the healthcare architecture, at least in the
Singapore context. This has been demonstrated in the KTPH case study as characterized
by attributes summarized in Table 5.3.
Table 5.3
Integrated design attributes of KTPH
S/No.
Attributes
A building typology exhibiting complexity in functions.
A project that has many stakeholders, spanning client (MOH), hospital

management (AH/KTPH), user groups, building consultants, contractors,
Reference
Section 1.1, 3.4.6
Section 3.3, 3.4
building authorities, agencies overseeing the community (PUB, HDB, NParks).

3
Early recognition and establishment of a multi-disciplinary team, comprising a

core project team supported by diverse expertise and user groups.
A triple-bottom-line approach, balancing economic and building performance,

social and human wellness, and environmental and ecological stewardship.
Section 3.4
Section 3.3
A robust visioning and objective setting process.
Section 3.3
Some degree of success in mindset change.
Section 4.3
A team-base, collaborative, integrated design process alternating

individual/small group research/design iterations and all stakeholders
Section 4.1 to 4.3
workshops, with an emphasis on partnership and team work.

8
Delivered a sustainable healthcare architecture as an integrated design

outcome.
123
Section 5.1
5.2
Lessons Learnt on the Practice of Integrated Design from the

KTPH Case Study
Based on the documentation study and interviews from the project team members, the
lessons learnt are as follows:
1. Briefing is a continuous process that intertwines with the design process.

2. Entrenched practice among building professionals.
3. Mindset change was not homogeneous among team members.
4. Lack of integrated design process toolkit.
5. Fragmentary design and documentation platform.
6. Issues related to contractor appointed via conventional approach.
5.2.1 The KTPH Briefing Process

The KTPH case study demonstrated that a close collaboration between the medical
professionals and building professionals had developed in the project. The design
process from masterplan, through schematic design, design development phases and
extended into contruction phase may be thought about as a long, collective dialogue,
allowing the stated objectives at the start of the project to be played out against other
constraints that are not apparent in the initial brief. These includes building authorities
requirements, budget, specific operational requirements that are only becoming visible
as building designers present the proposed internal layout, etc. As Lawson proposes,
Briefing is now generally regarded as a continuous process rather than one

which takes place exclusively at the start of the project. (Lawson, 2004. p. 13)
The eventual developed brief listed more than 440 specific requirements, categorized
under 15 categories, much more than the 31 objectives under 9 categories at objective
setting stage (Section 3.3; CPG file document)49.
49
Updated brief compliance checklist dated Mar 2007.
124
This highlights one of the key challenges in the design of healthcare architecture:
complexity. It also illustrates that design requirements, problems or constraints are
extremely difficult to be comprehensively stated, especially at the start of the project.
Very often, they are developed and defined as the possible solutions are being tossed
about (Lawson, 2005, p. 120). Hence, KTPH demonstrated that for large scale and
complex project, there is a need for close collaboration with stakeholders, experts from
different disciplines, and key decision makers in the iterative process, because problems
often only emerged after tentative solutions are proposed (See Appendix II on teambased design iteration).
5.2.2 Entrenched Practice among Building Professionals

Aside from the close collaboration between the medical and building professionals, the
project team members had highlighted in the focus group discussions that they
experienced a tendency among some building professionals to lapse into the
conventional behavior of linear, parallel processes. As a result, there are instances where
more straight forward design issues that building professionals could resolve among
themselves are less satisfactorily done, when far more complicated issues that require colearning between the healthcare and building professionals were resolve far more
satisfactorily. One likely explanation is that building professionals made assumptions
based on past experience and cut back on coordination with each other as they succumb
to time pressure; especially after committing huge amount of time and resources in the
co-learning process with the medical professionals.
This behavior tendency had occasionally crept into dealings with the medical
professionals as well. KTPHs Wai said that one short coming of the project team
members becoming very familiar and friendly with the KTPH staff, especially towards
the later phases of the project, is the tendency for individual building professionals to
seek consent from end users to resolve localized problems quickly, without seeking the
consent of the HPT or other inter-related departments. In other words, the problems may
not have been resolved systematically or holistically. This reveals that linear-thinking,
being an entrenched mode of thinking, is not easily replaced by system-thinking.
125
5.2.3 Issues Related to Mindset Change

Gathering from the interviews, it suggests that the mindset change among team
members was also not consistent: Some are more prepared to embrace collaboration and
adopt an open-minded attitude; others less so. This may be heavily influenced by the
background and personality of individual team members, and the organizational culture
where they belong to. In addition, the visioning and objective setting were heavily
focused on the healthcare perspective. With the benefit of hindsight, some sharing or
workshop emphasizing on system-thinking, e.g. between healthcare operation and built
environment, between nature and built environment, and between building systems
within the built environment, at the very early stage of the design process would have
been beneficial.
5.2.4 Lack of Integrated Design Process Toolkit

The Integrated design process guide or toolkits, some of which were briefly explored in
Section 2.3, were not available to the KTPH project team during the project. It is believed
that such toolkit would have provided a more systematic guide to better manage the
integrated design process.
5.2.5 Fragmentary Design and Documentation Platform

Computer aided design (CAD) was used as the predominant design and documentation
platform, supported by manual sketches, disparate software analysis tools and building
performance simulation software. This had resulted in a fragmentary design and
documentation process that has typically been troubling the building industry:
coordination between different sets of drawings. The complexity of the hospital
programme has simply compound the problem and hence workload.
126
5.2.6 Issues Related

Approach
to
Contractor
Appointed
via
Conventional
As the contractor was appointed in the conventional design-bid-build approach, they

were not included in the practice of integrated design. Coming on board after the tender
award, they had certainly missed most of the design iteration processes, where insights
and purpose of the project were reiterated through group dynamics and narration.50 In
addition, in keeping with the prevalent practice in the Singapore construction industry, a
large amount of construction detailed drawings were contractually the responsibilities of
the contractors, through the submission of shopdrawings to be checked by the building
professionals. In reality, the contractors simply could not cope with the demand of
designing and managing construction at the same time, especially under the intense
pressure of a fast track building programme. As a result, a significant degree of the early
good design intention faced implementation hurdles. A case in point is the need to lower
part of the ceiling heights in the wards due to the need to accommodate the M&E
services in the ceiling space, affecting the amount of daylight entering the wards.51
5.3
Discussion: the Practice of Integrated Design
Arising from the lessons learnt, further questions may be framed using Batshalom and
Reeds IDP Mental Model (Figure 5.2), as follows:
1. Who is the leader in integrated design? Specifically, without the leadership from
AH/KTPH CEO Liak Teng Lit, would the outcome for KTPH be the same? Can
we expect the architects, recognized as the leader of the building professionals, be
able to perpetuate the sustainability agenda and integrated design leadership
roles?52
Appendix II provides a theoretical reference on importance of team-based design iteration,

group dynamics, clients role in team-based design process, and conversation in team-based
design process.
51 With the benefit of hindsight, such occurrence may have been avoided if BIM was used to
coordinate the design during design development stage. This is indeed being done in some of
Singapore and CPGs current projects.
52 Refer also to Section 2.3.1 and footnote 15.
50
127
2. In the process of carrying out this research, one major challenge was the
investigation of the iterative process. As much of the iterative process was done
through conversation or narration, which were never completely and
comprehensively recorded in practice, the only way to investigate is via
interview based on project team members recollection. To facilitate the iterative
investigation or reflection, how can the conversational or narrative aspects of
design process be better documented?
3. Without participation from contractor, the integrated design process is

incomplete. How can Singapore develop a procurement method that allows
earlier participation of the contractors and fabricators?
4. How would most holistic process change, e.g. as proposed in AIAs integrated
project delivery (AIA, 2007) benefit integrated design and sustainable
architecture? How would it impact Singapores practice and industries?
Who is the
leader in the
sustainability
and
integrated
design
approach?
How can
Singapore
develop a
procurement
method that
allows earlier
participation of
the contractors
and fabricators?
How would a
holistic process
change
including a
design and
documentation
platform
facilitate
sustainable
architecture?
How can the

narrative
aspect of
design
process be
better
documented?
Figure 5.2 KTPH Integrated design process: questions framed with the IDP Mental Model
There are no immediate answers to these questions, but they serve as good starting
points as research areas in the knowledge and practice of integrated design, as
recommended in the next section.
128
5.4
Recommendations
Through the insights gained from the research, the following recommendations are
made to advance the knowledge and practice of integrated design in healthcare
architecture in the Singapore context:
1. To research into the construction and commissioning aspects of KTPH and their
impacts on the operational outcomes.
2. To conduct post-occupancy research along the triple-bottom-line approach on

KTPHs sustainability performance, as proposed in Table 5.4. Such research will
contribute to building up the body of works necessary to support evidence-based
design premised in Singapore.
Table 5.4
Areas of study proposed for sustainability performance of KTPH
S/No.
1
Attributes
Building performance in terms of energy and water saving benchmarked
against local and international data.
Measurement of clinician/staff morale and productivity improves due to

better physiological, psychological and sociological well-beings.
Measurement of patient well being and recovery time due to the social and
environmental (i.e. biophllic) attributes of KTPH.
Measurement of family and visitor well being due to the social and
environmental (i.e. biophllic) attributes of KTPH.
Effectiveness of community participation in KTPHs community stewardship

programmes due to the social and environmental attributes in KTPH
Enhancement of ecological outcome, e.g. improvements in biodiversity
Eco
Soc
Env

3. Conduct research into the narrative or design as conversations (Lawson, 2005)

aspects of the integrated design process, to better understand how design though
processes and decisions are arrived at in a group setting. It will contribute to the
knowledge and hence practice of integrated design, and perhaps even spawn a
129
new field of integrated design management. 53 This may provide valuable

insights in leveraging on architects skills as three-dimensional problem solvers
(Williams, 2007, p. 14) to also be an IDP champion and/or facilitator (Section
2.3.3.1).
4. To consider and research into holistic process change suitable for the Singapore
context, for example:
Collaborative practice model with BIM as the information platform (e.g.

integrated project delivery (IPD) as proposed by AIA, 2007; see Appendix III);
Early involvement of contractor and fabricator as stakeholders. This will

require a re-thinking in the procurement and execution method for building
contracts, e.g. IPD and lean construction principles (Abdelhamid, 2008) 54.
Just as lean principles have been appropriated in the manufacturing and

healthcare practices (Carpenter, 2012), 55 the emerging application of lean
principles in the design (Haynes, 2012)
56
and construction practices
(Abdelhamid, 2008) warrants further studies.
Sinclair (2008) commented that there are very few books devoted to the management of the
architectural design process (p. 1), and design management is the discipline of planning,
organising and managing the design process to bring about the successful completion of specific
project goals and objectives (Ibid., p. 4). The same rigour must surely be extended to the
integrated design process.
54 Lean construction refers to a production philosophy to minimize waste of materials, time, and
effort in order to generate the maximum possible amount of value. It requires the collaboration of
all project participants, client, consultants, contractors, facility managers, and users at early stages
of the project. This requires a new contractual arrangement where constructors and perhaps
facility managers play a role in informing and influencing the design (Abdelhamid, 2008).
55 In Lean-Led Design: Rules of the Road, Teresa Carpenter proposed that lean principles be
adopted as a systematic approach to healthcare architectural design that focuses on defining,
developing and integrating safe, efficient, waste-free operational processes in order to create the
most supportive, patient-focused physical environment possible. (Lean Healthcare Exchange,
2012)
56 In Adopting Lean Practices in the Architectural/Engineering Industry, David Haynes
proposed that lean processes in the manufacturing world could be translated in the AEC
industry through BIM (AECbytes Viewpoint #63). He proposed that Lean Design adopts
principles from business processes such as Six Sigma and Lean, and uses workflow techniques
that include workflow principles of Integrated Project Delivery (IPD), by combining the data rich
information in a BIM project with new workflow techniques to increase efficiency and reduce
waste [and] become more integrated in the project and gain greater customer satisfaction. (Ibid.)
53
130
During conceptual design, the owner is convinced

that the design team has a vision worth pursuing.
During the schematic design, the design team
convinces itself that the vision sold to the owner is
in fact feasible.
Alison Kwok and Walter Grondzik
Appendix I: Roles of Team Members By Design Phases
131
Appendix I
Source: Roadmap for the Integrated Design Process, p.107
132
Appendix I (Contd)
133
Appendix I (Contd)
134
Appendix I (Contd)
135
An iterative process allows communication at

every level, so that each team members design
decisions can be informed by an understanding of
how their works relate to the whole.
7group and Bill Reed
Appendix II: Iterative Process in Integrated Design
136
Appendix II
II.
Iterative Process in Integrated Design
By drawing from literature, this Appendix explores that iterative process in integrated
design as follows:
1) Design iteration in theory;

2) Team-based design iteration;
3) Various iteration methodologies to support integrated design.
1.0
Design Iteration in Theory
In How Designers Think, Bryan Lawson (2005), with inferences from earlier literature,
identified that design is an outcome of cognitive process, production process and
evaluation process; and often intertwines with these processes is the briefing process.
These are explored in Section 1.1 to 1.4.
1.1
The Cognitive Process
In the cognitive process, two types of thought processes are the most important in
design: reasoning/problem-solving and imaginative thinking. The former requires more
attention to the demands of the external world whilst the latter is primarily concerned
with satisfying inner needs through cognitive activity which may be quite unrelated to
the real world (Lawson, 2005, p. 138). This appears to echo the reseach/analysis phase of
the integrated design process (Dissertation Section 2.3.34).
1.2
The Production Process
A skilled or mature designer, with an ability to control the direction of his/her thinking,
is able to steer the thinking towards a desirable outcome, i.e. production. The two major
categories of productive thoughts are convergent and divergent production, the former
being the outcome of largely rational and logical processes, whilst the latter being the
outcome of largely intuitive and imaginative processes. Design clearly involves both
convergent and divergent productive thinking, and studies of good designers at work
137
Appendix II (Contd)
have shown that they are able to develop and maintain several lines of thoughts in
parallel (Ibid., p. 143).
Figure II-1 The whole host of issues to be considered in designing a window: one of the many
component and part of some inter-related systems in a building. Source: Lawson, 2005, p. 59
Lawson has also pointed out by way of the process of designing a window (Fig II-1) that
good design is often an outcome of integration. When dealing with a design as complex
as a building, in which there are many inter-related issues (or for Lawson, constraints),
there are many possibilities towards a well-integrated solution, and designers tend to
deal with it in two ways: generation of alternatives and by employing several parallel
lines of thoughts. Parallel lines of thought is a phrase first used by Lawson (1993) to
describe a parallel examination into different aspects of the same design, for example,
investigating detail and large scale issues in parallel (Lawson, 2005, p. 212), or say,
developing and sustaining many incomplete and nebulous ideas about various aspects
of their solutions (Ibid., p. 212), and traits of creative thought processes are often
observed in both. At this juncture, it is also important to recognize that in the generation
138
Appendix II (Contd)
of these alternatives, the designers are guided by their individual interests, approaches
and strategies as well as responding to requirements or constraints imposed by
legislation, clients, other consultants, and users (directly or indirectly); there are hence
many possible routes in the creative thought process (Ibid.). The generation of multiple
alternatives of thoughts allows the interplay between the values, issues, requirements,
problems and constraints to be tested visually, either as diagrammes, 2D drawings or 3D
visual rendering, on paper or computer/video display, as well as through conversation
(Ibid.). With reference to the integrated design process, this may possibly take place in
the reseach/analysis phase, or the workshop/charrette sessions of the integrated design
process (Dissertation Section 2.3.3.4).
1.3
The Briefing Process
Intertwines in the production process is often, but not always, a parallel process known
as the briefing process (Ibid.). In theory, the idealized design process assumes that a clear
design brief is established before the design even started. This assumption is based on
the premise that the design end product is a solution to some sort of problems, or needs,
hence the design problems or needs have to be defined up front (Ibid.). In practice,
however, it is found that design problems are often never fully described at the start of
the design process. Even if it is described in details, it often changes and evolves, because
the design process actually begins to develop the brief as it formulates a solution (Ibid.).
This is because good design often deal with the multiplicity of the values, issues,
requirements, problems and constraints by employing a very few major dominating
ideas which structure the scheme and around which the minor considerations are
organized. (Ibid., p. 189) The early generation of alternatives or parallel lines of
thoughts allows the interplay of values, issues, requirements, problems and constraints
to be tested and visually communicated with the project stakeholders: clients,
consultants, and sometimes builders and users. Such iterative process often helps to
shape and crystallize the brief:
139
Appendix II (Contd)
both empirical research and anecdotal evidence gathered from practising

designers suggest that the early phases of design are often characterised by what
we might call analysis through synthesis. The problem is studied not in minute
detail but in a fairly rough way as the designer tries to identify not the most
important (to the client) issues, but the most crucial in determining form. Once a
solution idea can be formulated, however nebulous it may be, it can be checked
against other more detailed problems. (Lawson, 2005, p.p. 197-198)
It is interesting that these and other designers studied who use the generation of
alternatives, often show them to their clients. This seems to become part of the
briefing process; a way of drawing more information out of the client about what
is really wanted. (Ibid., p. 210)
An understanding of the briefing process in KTPH may be gained by reading Sections

3.3 and 5.2.1 of this dissertation.
1.4
The Evaluation Process
Eventually, the ideas produced will need to be evaluated, and decisions of which ideas
to be adopted and integrated into a holistic solution will have to be made. Designers
must be able to perform both objective and subjective evaluations and be able to make
judgements about the relative benefits of them even though they may rely on
incompatible methods of measurement (Ibid., p. 298). For the integrated design process,
this is recommended to take place in the all-stakeholders workshop sessions
(Dissertation Section 2.3.3.4).
2.0
Team-Based Design Iteration
So far, the designer has largely been described as a person. With the exception of small
scale projects e.g. single-family house, building projects usually involve many people in
a design team, comprising architects, who are likely to have team members focusing on
different aspects of the project, as well as civil & structural engineers, mechanical &
140
Appendix II (Contd)
electrical engineers, and possibly many other specialized consultants, such as quantity
surveyor, landscape architect, interior designer, lighting consultant, acoustic consultant,
etc. Many of them will handle a certain aspects of design.
This brings about a second characteristic of design in practice, which is vital to teambased integrated design process: besides being a cognitive process, design is also a social
process, in which the rapport between group members can be as significant as their
ideas. (Ibid, p. 240)
Both the individual specialist teams and the overall project team can be seen to
exhibit group dynamics, and to behave not just as a collection of individuals. An
examination of professional diaries is likely to show that most architects spend
more time interacting with other specialist consultants and fellow architects, then
working in isolation. (Ibid., p.239)
2.1
Group dynamics
It is hence worthwhile to explore the notion of group dynamics. A group acts not just as
a collection of individuals, but also in a manner somehow beyond the abilities of the
collective individual talents (Ibid., 239). What characterize a group are:
1) They share a common goal;

2) They develop a set of norms, which guide their behavior and activities;
3) They develop interpersonal relationships.
The development of group norms leads to a suppression of the individuality of its

members, in favour of an expression of attachment to the group (Ibid., p.244). As
norms developed over time, often through conflict resolution, it results in a common
perception of the groups goal and individuals acquiring and accepting roles within the
group, and these roles simultaneously often help to facilitate the business of the group
and become part of the folklore which binds the group together (Ibid., p. 246).
141
Appendix II (Contd)
Many high-performing design practices are found to be also strong social groups,
formed after overcoming internal strives or external challenges. They developed shared
language and common admiration for previous design work (Ibid., p. 250), and relied
heavily on the sharing of concepts and agreed use of words which act as a shorthand
for those concepts. (Ibid., p. 250) The intensity of the design process demands that such
shorthand be used during conversations. At the same time, the social nature of team
work, the communication and co-operation in realizing design as a collective process is
rewarding for many designers (Ibid.).
2.2
The Clients Role in Team-Based Design Process
The benefits of group dynamic often extend to include the client:
Behind every distinctive building is an equally distinctive client. (Michael

Wilford, in Lawson, 2005, p. 254)
Many designers value continual engagement with the client, in the process developing a
trusting relationship with client. From the clients perspective, trust is needed because
building professionals are designers that clients expect to be protected from his or her
own ignorance by such a professional (Lawson, 2005, p. 255). From the designers
perspective, without trust, creativity and innovation in design is unlikely to take place,
as any thought or process perceived as uncertain, ambiguous, and vague, will be
doubted or rejected by the client, which undermines the very nature of the divergent
thinking process (Ibid.).
In big projects, client is often also represented by a group or committee. Needless to say,
client group or committee that experiences frequent changes in its members would suffer
setback in the trust-building process, as well as potential reduction in commitment to the
project by both client and designer (Ibid.).
142
Appendix II (Contd)
2.3
Conversation and Perception in Team-Based Design
During the production process, it is noteworthy that good designers are able to sustain
several conversations with their drawings, each with slightly different terms of
reference, without worrying that the whole does not yet make sense. This important
ability shows a willingness to live with uncertainty, consider alternative and perhaps
even conflicting notions, defer judgement, and yet eventually almost ruthlessly resolve
and hang on to the central idea (Ibid., p. 219). While such traits are valuable to an
individual designer, the ability to conduct design as a conversation becomes even more
crucial in a team design process.
In large or complex project e.g. hospital in which a multi-disciplinary design team is

required, including professionals and experts from different fields, increased
conversations between team members enable the following to take place:
1) Build up trust;
2) Identify the central elements of the design through a narrative process (Ibid., p.
267);
3) Negotiate to reconcile conflicts in ideas and concepts, enabling the team to

navigate from problem to solution. The parties come into the negotiation taking
different views and having different objectives but with a willingness to reach
some form of agreement that all parties can accept (Ibid., p.271)
4) To communicate shared experience, e.g. shared concepts, past problems and

solutions, etc. These shared concepts are transmitted via conversational
shorthand to facilitate the intense iteration process in design. At the same time,
such shared experience helps to forge social bond between the design team
members.
143
Appendix II (Contd)
2.4
The Problem and Solution Views in Team-Based Design
The conversational nature of the design process is seen also in the negotiation between
problem and solution. This leads to the heart of the design process, which led Lawson to
state that:
...designers tend to be solution focused rather than problem focused in their

approachthey tend to acquire considerable stores of knowledge about solutions
and their possibilities and affordances.
So designers have the task of negotiating reconciliation between these two views
of the situation they are dealing with. The problem view is expressed generally in
the form of needs, desires, wishes and requirements. The solution view on the
other hand is expressed in terms of the physicality of materials, forms, systems
and componentsWe do not see designing as a directional activity that moves
from problem through some theoretical procedure to solution. Rather we see it as
a dialogue, a conversation, a negotiation between what is desired and what can
be realized (Ibid., p.p. 271-272).
Conversation 57 is engaged between the designer and his/her sketches, drawings,

computer visualization. In team-based design, conservation through words as well as
drawings and visual representation is likewise engaged between the designer and
paying client, between fellow designers, and between designer and users. In an extensive
process, the conversation may also be engaged between the designer and builder, and
between the designer and product/component manufacturer. The early involvement of
builders and manufacturers are advocated in the integrated design approach, and the
experience from KTPH appears to support such an advocacy. In the KTPH project, the
conventionally appointed contractors, being late comer on the project, did not enjoy the
This conversation may also be understood as iteration loops (Heiselberg and van der Aa,
2010).
57
144
Appendix II (Contd)
benefits of early involvement and hence understanding the design objectives and
processes (See Chapter 5 of this dissertation).
It is also important to note that:
1. Design problems tend to be organized hierarchically (Lawson, 2005, p. 121).

While there is no fixed or logical sequence to tackle the problems, it is generally
sensible to tackle the problems that imposed the most constraints, before
progressing to those with lesser constraints. This is supported by van der Aa,
Heiselberg and Perinos interative design model (Section 3.2 of this Appendix),
and validated through the examples examined for the KTPH case study: the site
layout and massing form and proportion was first determined in the masterplan
stage, followed by envelope design for the various blocks in the schematic and
early design development stage, before system design and component design in
the late design development stages were carried out.
2. Design problems58 require subjective interpretation (Lawson, 2005, p. 120-121).

What seems important to one client in one project may not be necessary so to
another client or in another project. Communication and establishing mutual
understanding is required.
Lawson has also written about the continuous and interacting relationship between
problem-definition and solution-finding in the design process:
1. Since design problems cannot be comprehensively stated, there are an

inexhaustible number of design solutions (Lawson, 2005, p. 121).
2. There is no one best solution to design problems; many acceptable solutions are
possible, each proving more or less satisfactory to different client and users
(Lawson, 2005, p. 121-122).
Design problems here may also be understood as design requirements, design constraints,
design issues, and/or design challenges.
58
145
Appendix II (Contd)
3. Design solutions are often holistic responses (Lawson, 2005, p. 122).

4. Design solutions are a contribution to knowledge (Lawson, 2005, p. 122).
5. Design solutions are parts of other design problems (Lawson, 2005, p. 122-123).
This leads to the need to involve stakeholders, experts from different disciplines, and key
decision makers in the iterative process, because problems often only emerged after
tentative solutions are proposed. This is especially the case for a large, complex project
with highly specific requirements such as a hospital.
2.5
Mindset and Cultural Change Needed in Team-Based Integrated

Design
The problem-solution model of the design process is also put forth by Michael Brawne
(2003), who sees a parallel in the cyclical design sequence in the Popperian59 sequence of:
P1 TS EE P2 (Problem recognition, Tentative Solution, Error Elimination, best
corroborated solution which becomes the problem to the next sequence). It is important
to note that in the design process, the starting problem can occur both within and
outside architecture but more often than not manifests itself as a problem in architecture
irrespective of its originWe start with a verbally stated problem but very soon have to
shift into non verbal-thinking (Brawne, 2003, p.p. 33-35). This underscores the
quintessence of architectural design: the need to recognize a host of problems (often
fragmentary and inter-contradicting), which are initially describable only in words (and
sometimes inaccurately described or scantly described), test it through one or more
tentative solutions (multiple line of thoughts) that are by necessity expressed in nonverbal terms (e.g. drawings, computer models, physical models), before it could be
evaluated (error-elimination; is it acceptable to client? Does it comply with codes and
Named after Sir Karl Raimund Popper. In All Life is Problem Solving, the Popperian sequence
(PS1 TT EE PS2) was proposed as a model for scientific advancement, in which the degree
of truth in scientific theories are only true for its time (TT, tentative theories); further research
and processes (EE, error elimination) will always yield better theories. In such cyclical process,
scientific knowledge thus advances from lower grade problem situations towards higher grade
ones (PS1 to PS2).
59
146
Appendix II (Contd)
regulations? Are there conflicts between different disciplines?), before it is deemed to be

acceptable for further development (a holistic corroborated solution; an overall solution
that integrates the host of solutions to the problems that had been recognized).
It is also noteworthy to note that in the design sequence P1 to P2, a great many initial
problems are self imposed and often arise from visual choices (Ibid., p. 259). He
described the way many architects design:
Before we use models in the tentative solution, in the design stage, we are
involved in problem selection. We cannot and do not solve all the problems
which exist at that time in that projectThere are the demand set by the brief
which require resolution but in addition to that we ourselves see problems or
have
leanings
to
particular
resolutions
which
makes
for
individual
responsesProblem recognition and what is imaginable are conditioned by the

world around us.
It is the severity and nature of the self-imposed problems which are the test of
architectural greatness. To satisfy the architectural programme of space,
adjacencies, circulation, service provision and so on is a difficult and necessary
task. It is the basis of much design. In the last resort, however, it is a
journeymans taskPoetry and delight are the task of the master and arise from
self-imposed necessities. It is also the solution of the problems which we set
ourselves which produces the greatest agonies and delight of design. (Brawne,
2003, p. 62)
What Michael Brawne has just described, is perhaps the secret to how architects have
rather universally been taught and practiced; the values first transferred from teacher to
student in architectural school, and later from master to apprentice in practice. It is by
nature a rather self-centred process, which presents a challenge to the integrated design
process (IDP), as IDP demands that architects fundamentally alter their role, to listen and
be open-minded to admit inputs from many other sources. But giving up control goes
147
Appendix II (Contd)
against everything architects are taught (Deutsch, 2011, p. 136). Feedback received from
green consultant Alvin Woo from CPGreen, CPG Consultants environmental
sustainability studio appears to reflect this, Many of the external enquiries requesting
for our involvement are projects that architectural concept design have been determined.
There is often a limit to what we could offer, especially in passive response to site and
climate, without requiring some fundamental changes to the architectural concept.
On the other hand, there is a reluctance among the engineers to contribute in a more
broad-based manner. Some, if not most practising engineers in Singapore appeared to
have been conditioned to start thinking only after the architectural concept design had
been generated and handed off to them. The other common trait observed from M&E
engineers, perhaps reflecting the challenges they are confronted with, is the tussle
between the concern for under-performing design and the need for innovative
engineering approach which is often perceived as untested method, high risks, and
unknown liabilities. In addition, the disconnect between the engineers and the
construction and manufacturing companies in Singapore practice further exacerbates the
problem. While engineers provide general design, the actual design and installation had
to be tendered out and worked on by the contractors and manufacturers who won the
tender, based on the actual product or construction method used. The opposing
positions between the clients (who wish to pay less) and contractors/manufacturers (who
wish to claim for more) often leads to adversities and disputes, with engineers caught
out between two parties. In the healthcare context, complexity in the M&E systems
simply further amplifies the challenges.
Jerry Yudelson pointed out that,
Integrated design is not as easy as changing your shirt every day; old habits die
hard. To me, it appears that air-conditioning has made mechanical engineers
reactive for decades, because no matter how the architect designs the building,
they can still provide more or less adequate comfort by adding air-conditioning
tonnage. There are also the risks of trying new things; every departure from
148
Appendix II (Contd)
normal design practices, no matter how intelligent, runs the risk of a lawsuit if
things dont work out as planned. To make integrated design work, the team
often has to challenge prevailing codes. This is how progress is made, but it isnt
easy or fast. (Yudelson, 2009, p. 63)
As a result, for the integrated design approach to be successful, it has to start with
mindset change and alignment from all stakeholders, including client, architect,
engineers, specialist consultants, users, and many other stakeholders (See Section 2.3.2 of
this dissertation). The mindset change needs to be supported by social techniques:
fostering collaborative spirit through a healthy, encouraging and trusting social process
and group dynamics as explored in Section 2.1 to 2.3 of this Appendix, and Section
2.3.4.2 of this dissertation. In addition, the team-based iterative process may be facilitated
by iterative tools or methodologies, which are explored in the next section.
3.0
Methodologies in Integrated Design Iteration
The design iteration methodology is an emerging field, and this section examines some
of the methodologies, as follows:
1) Integrated Design Process (IDP) by Sustainable Built Environment (iiSBE)

2) Strategies for Integrative Building Design (Heiselberg and van der Aa, 2010)
3) Rethinking the Design Process, a presentation by Konstrukt (2006)
3.1
Integrated
Design
Process
(IDP)
by
Sustainable
Built
Environment (iiSBE)
The International Initiative of Sustainable Built Environments (iiSBE) Integrated Design
Process (IDP) claimed that IDP contains no elements that are radically new, but
integrates well-proven approaches into a systematic total process (Larssons, 2004, p. 2).
The salient point to highlight in the iiSBE IDP process is the presence of feedback loops
in its process (Figure II-2), which is a form of team-based iterative process.
149
Appendix II (Contd)
Figure II-2 iiSBE Integrated Design Process. Source: iiSBE (Larsson, 2004)
The feedback loops in Figure II-2 illustrate the inter-activity between building envelope
design, daylighting/lighting design, power design, ventilation, heating, and cooling
design. Throughout the iteration, the focus is on the performance targets established for
a broad range of parameters and as consensus between designers and client (Ibid., p.p. 23). Specific recommendations by IDP pertaining to team-based iteration include:
1) Iterate the process to produce at least two, and preferably three, concept design
alternatives, using energy simulations as a test of progress, and then select the
most promising of these for further development (Ibid., p. 3).
2) Budget restrictions applied at the whole-building level, with no strict separation
of budgets for individual building systems, such as HVAC or the building
structure extra expenditures for one system, e.g. for sun shading devices, may
reduce costs in another systems, e,g, capital and operating costs for a cooling
system (Ibid., p. 2).
150
Appendix II (Contd)
3) [T]he addition of a specialist in the field of energy engineering and energy

simulation (Ibid., p. 2).
4) [T]esting of various design assumptions through the use of energy simulations
throughout the process, to provide relatively objective information on this key
aspect of performance (Ibid., p. 2).
3.2
Strategies for Integrative Building Design
Heiselberg and van der Aas (2010) model of the iteration loop has been briefly presented
in Section 2.3.3.4 of the dissertation. The objective of the iteration is to achieve what they
termed as responsive building concepts (Ibid., p. 2), which refer to
[D]esign solutions in which an optimal environmental performance is realized

in terms of energy performance, resource consumption, ecological loadings and
indoor environmental quality. It follows that building concepts are design
solutions that maintain an appropriate balance between optimum interior
conditions and environmental performance by reacting in a controlled and
holistic manner to changes in external or internal conditions and to occupant
intervention and that develop from an integrated multidisciplinary design
process (Ibid., p. 2).
They proposed that an integrated building concept can be defined to consist of three
parts: an architectural building concept, structural building concept, and an energy and
environmental building concept (Ibid., p. 2, Figure II-3).
Figure II-3 Integrated Building Concept. Source: Heiselberg and van der Aa (2010).
151
Appendix II (Contd)
To achieve that, a multi-disciplinary approach is required to develop various design

strategies (Ibid., p. 6, Table II-1), from macro to micro, from broad-based to specific
details, through the design phases (Ibid., p. 8, Figure II-4).
Table II-1 Typical design considerations at each design phase.

Source: Heiselberg and van der Aa (2010).
152
Appendix II (Contd)
Figure II-4 Iterative Process. Source: Heiselberg and van der Aa (2010).
Similarly, Heiselberg and van der Aa propose that iteration loops (Figure II-5) are
expected to characterize each of the design phases, allowing tasks (problems in Section
2.4 of this Appendix) and results (solutions in Section 2.4 of this Appendix) to be
iterated taking into consideration input[s] from other 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).
Figure II-5 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].
153
Appendix II (Contd)
3.3
Rethinking the Design Process
In Rethinking the Design Process, a presentation by Konstrukt (2006), they propose that
integrated design is a systems approach [that] has the potential to create buildings with
lower first costs and large energy savings (Ibid., slide 2), and that the fundamental
process of integrated design is the search for synergies. Synergistic strategies create
benefits greater than the sum of the individual design decisions (Ibid., slide 3). Their
primary concern is building energy consumption, which is defined as a function of
climate, building use, and site & building design (Figure II-6).
Figure II-6 Building energy loads as presented in Rethinking the Design Process.
Source: Konstruct (2006).
They presented a succinct approach a design attitude of a double strategy of (Figure

II-7):
1) Reducing energy load demand, say by 50% e.g. through good bioclimatic and site
response, adopts passive design strategies, right-sizing of user receptacle load,
etc;
2) Doubling system efficiency.
154
Appendix II (Contd)
Figure II-7 Approach to reduce energy consumption as presented in Rethinking the Design
Process. Source: Konstruct (2006), slide 10.
Such thinking conceptually demonstrates that an ambitious objective of reducing energy

consumption to 25% of a typical, conventional design is plausible, and along the way
perhaps even resulting in cost saving in the system designs (Ibid.). This simple and
succinct approach is indeed an effective way to establish the right shared mindset
among the stakeholders, an important first step that leads to team visioning and setting
high objectives. Such objectives have to be supported by team collaboration and
integrated design. Konstruct proposed a model to understand the components of
integrated design process, comprising: design topics, iterative process, energy topics,
and tools & data to find synergies (Figure II-8 and Figure II-9). While not explicitly
stated, the iterative process is expectedly multi-disciplinary and team-based, in order to
meet the diverse range of knowledge and skill sets needed for the problem definition,
solution finding, and search for synergies (Figure II-9).
The heart of the integrated design processis the search for synergies between
two or more attributes of climate, use, design, and systems, that will result in
combined performance, exceeding the sum of their individual performances, and
reduce project first cost and operating expense.
(Konstruct, 2006)
155
Appendix II (Contd)
Figure II-8 Components of integrated design process presented in Rethinking the Design
Process. Source: Konstruct (2006).
Figure II-9 The search for synergies between two or more attributes of climate, use, design, and
systems as presented in Rethinking the Design Process. Source: Konstruct (2006).
156
A BIM methodology seeks to adapt to the added

layers of information, allowing new methods of
data exchange and communication amongst all the
stakeholders in a project. This can be the design
team (designers and consultants), builders
(contractors and subcontractors), and owners
(developers and facility managers)The goal of a
BIM methodology is to allow an overall view of the
building or project by including everything in a
single-source model.
Eddy Krygiel and Bradley Nies
Appendix III: Building Information Modelling
157
Appendix III
III.
Building Information Modeling
By drawing from literature, this Appendix briefly explores the relationship between
building information modeling (BIM) and integrated design, sustainable design and its
relevance to practice, as follows:
1) Brief Definition of BIM.

2) BIM, integrated design and sustainable design
3) BIM and integrated project delivery (IPD) (AIA, 2007).
1.0
Brief Definition of BIM
Krygiel and Nies (2008) defined BIM as, an emerging tool in the design industry that is
used to design and document a project, but is also used as a vehicle to enhance
communication among all the project stakeholders (p. 25). It is first and foremost an
informational technological (IT) platform for building design and documentation with
the characteristics summarized in Table III-1.
Table III-1
Characteristics of BIM.
S/No.
Event
1.
BIM is information about the entire building and a complete set of design documents stored in an
integrated database (Ibid, p.26) [Italic emphasis by author].
All the information is parametric and thereby interconnected (Ibid, p.26) [Italic emphasis by
author].
Any changes to an object within the model are instantly reflected throughout the rest of the project
in all views (Ibid, p.26) [Italic emphasis by author].
A BIM model contains the buildings actual constructions and assemblies rather than a twodimensional representation of the building that is commonly found in CAD-based drawings
(Ibid, p.26) [Italic emphasis by author].
A BIM model can be holistically used throughout the design process and the construction
process. (Ibid, p.27).
BIM methodology allows
2.
3.
4.
5.
6.
But more importantly, it entails an entire re-think in workflow in order to fully harness
its benefits (Table III-2). The main challenge being confronted in the industry, is not
technological in nature, but a resistance to work flow change due to mindset and attitude
(Deutsch, 2011, p. x; Figure III-1 and III-2). Since it needs to be approached as a change in
method and workflow (Krygiel and Nies, 2008, p. 43), it shares many similarities with
the need for mindset change in integrated design, as presented in the next section.
158
Appendix III (Contd)
Table III-2
Benefits of BIM. Source: Krygiel and Nies (2008)
S/No.
Event
1.
3D Simulation versus 2D representation (Ibid, p.34): permitting clashes of building

elements and components to be viewed in virtual 3D space on computer display.
Accuracy versus estimation (Ibid, p.34): By allowing the building design to be
constructed virtually before its physical implementation, BIM adds a layer of accuracy
to both building quantities and qualities (Ibid, p.p. 34-35).
Efficiency versus redundancy (Ibid, p. 35): By adding building objects to the design
once, instead of drawing the same object in different views, time saving is achievable.
Intelligent representation: A BIM model contains the buildings actual constructions
and assemblies rather than a two-dimensional representation of the building that is
commonly found in CAD-based drawings (Ibid, p.26) [Italic emphasis by author].
Project lifecycle: A BIM model can be holistically used throughout the design process
and the construction process. (Ibid, p.27)
Integrated document: As all of the drawings in a BIM model are placed within the
single, integrated database or model, document coordination becomes relatively
automatic (Ibid, p.38).
Design visualization: Since the model is in 3D, it can be viewed and turn around for
visual examination, unlike 2D drawings which are susceptible to subjective
interpretation and miscommunication, especially if lay persons (e.g. users) are involved
(Ibid, p.38).
Material database: Since BIM model is also a database of the virtual building, if the
models of building components and assemblies are created with their physical
properties, automation of scheduling and quantity take off can be achieved (Ibid, p.39).
Sustainable strategies: The building geometry from the model may be used internally
within BIM or exported for analysis to support sustainable design, e.g. energy modeling
and daylight modeling (Ibid, p.40).
Construction planning: Contractor familiar with BIM can utilize the model for
visualization, planning and coordination, to avoid errors and waste during
implementation. It may also facilitate digital workflow from design to fabricator, since
the information is all in 3D (Ibid, p.40).
Postoccupancy and facilities management: The BIM model may be utilized by building
owner and facilities managers for asset management and equipment tracking (Ibid,
p.40).
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Figure III-1 Common erroneous perception is that BIM is primarily a technology change (left).
Instead, Deutsch (2011) argued that in reality, BIM is about sociological change, involving
practical, attitudinal, and behavioral changes. Source: Deutsch (2011), p. x.
159
Figure III-2 The business and technology cases for BIM and integrated design have already
been made. It is time to make the social case for firm culture, including working relationships,
interactions, and intelligence. Source: Deutsch (2011), p. xi.
2.0
BIM, Integrated Design and Sustainable Design
The case for integrated design has been made in Chapter 2 of this dissertation. The
causes that give rise to the needs for integrated design and BIM are in fact quite the same:
specialization and fragmentation of the building knowledge and technologies, and hence
a need for integration. To support sustainable design, new specialized knowledge and
design layer e.g. solar analysis model, energy model, daylighting model have indeed
added additional design layers and complexity to the traditional physical design model,
digital
design
model,
authority
submission
documentation
and
construction
documentation (Ibid, p.p. 46-52; Figure III-3). All intent and purpose of BIM is to
facilitate and streamline an integrated workflow (Figure III-4). As BIM processes
Figure III-3 Layers of design information. Source: Krygiel and Nies (2008), p. 55.
160
Appendix II (Contd)
becomes truly owned in practice, higher productivity, higher quality work, and new
possibilities, e.g. integrated design and sustainable design become attainable (Deutsch,
2011; Figure III-5).
Figure III-4 BIM Roadmap. Source: Krygiel and Nies (2008), p. 52.
Figure III-5 BIM as processes. Deutsch (2011), p. 6.
161
3.0
BIM and Integrated Project Delivery
Developed by the American Institute of Architects (AIA), Integrated Project Delivery

(IPD) is a project delivery approach which integrates people, systems, business
structures and practices into a process that collaboratively harnesses the talents and
insights of all participants to optimize project results, increase value to the owner, reduce
waste, and maximize efficiency through all phases of design, fabrication and
construction (AIA IPD Guide, 2007). It has an ambitious aim to not only incorporate
design into its process, but goes beyond that to attempt to bridge the gap between design
and construction (Ibid.)
In the IPD process map (Figure III-6), the full project team is identified and involved
much earlier in the process, including the builders and fabricators. More time is spent in
the design phase, to allow team-based integrated design process to take place, with ideas
Figure III-6 Integrated Project Delivery Process versus Traditional Process

Source: Integrated Project Delivery: A Working Definition, (2007), pp. 4.
162
supported by and tested out using a variety of tools, e.g. sketches, technical calculations,
computer modeling and simulations. In contrast, the documentation, buyout (client
approval) and agency (authority approval) phases require less time based on a set of
well-resolved detailed design document (IPD Working Definition, 2007).
Although it is not a mandatory tool, BIM is explicitly stated and promoted in IPD. Figure
III-7 by Autodesk, a BIM software vendor, illustrates the utilization of BIM throughout
the IPD project life cycle.
IPD represents a substantial industry-wide process change, and its principles, values and
relevance for the Singapore context need to be further examined.
Figure III-7 Integrated Project Delivery with BIM. Source: Autodesk (2008).
163
The process and science of building design has

become increasingly more complicated in recent
years. It has continually become less possible for
designers to work without the aid of other
specialists, be they consultants or contractors.
The trend toward concentrated areas of expertise
has led to a growing movement to combine the
owner, designer, contractor, consultants, and key
subcontractors into an integrated design team.
Appendix IV: Design Consortium of the KTPH Project
164
Appendix IV
IV
Design Consortium of the Khoo Teck Puat Hospital Project
Key Project Team Members (team members interviewed in focus group discussions are
highlighted in bold)
Role
Company
Name
Liak Teng Lit
Chew Kwee Tiang
Pang Weng Sun
Francis Lee
Wong Moh Sim
Low Beng Hoi
Yen Tan
Ng Kian Swan
Donald Wai
Koh Kim Luan
Cynthia Ong
Sim Siew Ngoh
Esther Yap
Lye Siew Lin
Poh Puay Yong
Rosalind Tan
Chong Choon San
Tan Kok Siong
Puah Chin Yee
Yip Sing Keat
Jean Yeo Fei Shien
Albin John
Khoo Teck Puat Hospital Users

(Medical Professionals)
AHPL
Project Manager
PMLink Pte Ltd
Building Professionals
Project Director/Architect
Lee Soo Khoong
Architect
Lim Lip Chuan

Pauline Tan
Jerry Ong
Kanda Narasimhan
Cherilyn Chan Yin Yuet
Mahesh M G
Healthcare Architectural
Consultant
RMJM Hillier
Peter Schubert
Sung Won Lee
Noah Burwell
Medical Planner
Medical Planning Research (MPR)

International
Ray Skorupa
Civl & Structural Engineer
Mechanical Engineer
Electrical Engineer

Landscape Consultant
Total Building Performance Team

Peridian Asia Pte Ltd
Quantity Surveyor
Interior Design Consultant

Facade Consultant
Wayfinding Consultant
Signage Consultant
Bent Severin & Associates Pte Ltd

Aurecon Singapore (Pte) Ltd
Space Syntax Australia PTY Ltd
Design Objectives Pte Ltd
165
Soon Chern Yee

Tan Swee Keng
Sumay Tan
Toh Yong Hua
V Devaraja
Heng Chen Han
Wong Lee Phing
Melvin Yap
Dr Lee Siew Eang
Glenn Bontigao
Yeo Tiong Yeow
Tan Hui Choo
Raymond Koh Kok Yong
Grace Soh, James Wong
Lily Low, Sigmund Mendiola
Martin Butterworth
Ronnie Tan, Lawrence Tong
What is this mysterious label and what does it

mean? How do you know you really are practicing
integrative design or not? How does a client know
who to believe when selecting a team?
Barbra Batshalom
Appendix V: Interview Guide
166
Appendix V
A. Based on Whole System Integrated Process (WSIP, 2007), the process stages in IDP may be categorized
as follows:
Stage
1.
Team Formation
Elements
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
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

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.
6.
Construction &
Follow through during the Construction Process.
Commissioning
Commission the project.
Post-occupancy Feedback
Maintain the system.
Loops
Measure performance and respond to feedback - adjust key aspects of the system accordingly.
B.
Based on Roadmap for the Integrated Design Process (Roadmap IDP, 2007), team organization are
compared between conventional and integrated design team:
1.
2.
Which one do you think better describe KTPH design/project team organization? Answer (1 or 2): _______
167
Appendix IV (Contd)
C.
Based on Whole System Integrated Process (WSIP, 2007), team organization are compared between
conventional and integrated design team:
1.
2.
Which one do you think better describe KTPH design/project design process? A: ______________
D. Are you familiar with the following integrated design/whole design process or methologies:
Factors
S/No.
1.
iiSBEs C2000 Program to Integrated Design Process (IDP) (Larsson, 2004). A roadmap
basing on the IDP, developed by Busby Perkins+Will and Stantec Consulting for the British
Columbia Green Building Roundtable, Canada
2.
The Integrative Process (7Groups et al, 2009) that seeks to optimize the interrelationships
between all the elements and entities associated with building projects in the service of
efficient and effective use of resources.
3.
Whole Systems Integrated Process Guide for Sustainable Buildings & Communities
(ANSI/MTS Standard WSIP 2007). Developed by a committee of practitioners and gained
approval as a public standard in US, it codifies the meaning, importance, and practice
structure of an Integrated Design Process.
4.
Road Map for the Integrated Design Process (Busby Perkins+Will and Stantec Consulting,
2007). Developed for British Columbia Green Building Roundtable, Canada, to serve as an
industry practice guide. It is divided into two parts: Part One: Summary Guide; and Part
Two: Reference Manual. Part One provides an overview of IDP, while Part Two is intended
to serve as a reference manual.
5.
The Integrated Design Process in Designing with Responsive Building Elements (van der Aa,
Heiselberg and Perino, 2011). Published under the IEA (International Energy Agency)
Energy Conservation in Buildings and Community Systems (ECBCS) Programme.
6.
The Whole Building Design Guide (WBDG) (Prowler, 2011) is a web-based Whole Systems
Integrated Process Guide for Sustainable Buildings & Communities (ANSI/MTS Standard
WSIP 2007). Developed by a committee of practitioners and gained approval as a public
standard in US, it codifies the meaning, importance, and practice structure of an Integrated
Design Process.
7.
Integrated Project Delivery (IPD) developed by American Institute of Architects (Integrated

Project Delivery: A Guide, 2007).
168
During KTPH
Now
project (Yes/No)
(Yes/No)
Appendix IV (Contd)
169
Appendix IV (Contd)
170
Appendix IV (Contd)
171
Appendix V (Contd)
172
Good design, that is evidence-based, does not cost

money but will show significant savings over the
life-cycle of the building, as well as improving the
quality of life for all occupants.
Bryan Lawson
Appendix VI: Evidence-Based Design Principles
173
Appendix VI
VI.
Evidence-Based Design Principles
The integration of natural and landscape elements in KTPHs site planning and layout
had facilitated the following benefits supported by the following evidence-based design
studies:
1. Positive effects of natural environment in the healthcare environment.

2. Improves way-finding leading to reduced stress.
1.0
Positive Effects
Environment
of
Natural
Environment
in
Healthcare
The biophilia hypothesis suggests that there is an inborn affinity within humankind with
nature and living systems, including plant life, animals, as well as climatic elements e.g.
the sun and natural light and warmth, breeze, sound, and so on (Wilson, 1984; Kellert et
al, 1993; Kellert, 2004). The hypothesis has found support in parallel studies in the field
of environmental psychology, which examines the inter-relationship between human
and physical environment, be it natural or constructed (Section 1.6.2). One of the
findings is, not only is humankind aesthetically attracted to nature and living systems,
the sensing of with these features is also found to have positive effects on human
functioning and reduces stress (Bell, 2001; Bechtel, 2002). According to Ulrich (2002), the
healing properties of nature and natural systems have long been known, but have been
overshadowed by advances and focuses in medical technology and science, as well as
concerns for operational efficiency. The mounting evidenced-based studies more
recently have nonetheless strengthened the case for bringing nature into healthcare
environment to achieve the benefits as briefly explored in Section 1.1 to 1.5.
1.1
Speeding Up Patient Recovery and Enhancing Patient Well-being
Research has shown that stress and psychosocial factors can significantly affect patient
health recovery (Ulrich, 2001; Dellinger, 2010). Since human responds psychologically
and physiologically to nature and landscape positively (Ulrich, 1986), integrating nature
174
Appendix VI (Contd)
and landscape into healthcare built environment e.g. through the notion of the healing
garden (Ulrich, 1999, 2002; Shermana et al, 2005), or simply giving access to view
through window to nature and natural system have led to better postoperative outcome,
including the need for less pain medication, shorter lengths of stay, and few minor
complications,and generally reported better emotional well-being (Ulrich, 1984;
Dellinger, 2010).
Based on the mounting evidence, Dellinger (2010) recommended that: When

designers plan a healthcare facility, they need to make actual nature, such as healing
gardens or landscaped areas with private setting, or the suggestion of nature
(through photos, murals, or sculpture), as integral part of the design (p.64). Other
studies suggested the use of water features as a positive distraction, even briefly, that
cause positive emotional response (Joseph, 2006). Figure 3.3 and 3.4 illustrate the
various ways in which KTPH had integrated nature, landscape and water feature
into its built environments.
Figure VI-1 View to nature: Yishun Pond viewed from the Central Courtyard.
175
Appendix VI (Contd)
Figure VI-2 Private seating corner around water as therapeutic modality: Courtyard at Basement
1 in Khoo Teck Puat Hospital featuring a small landscape pond. Source: CPG Consultants Pte Ltd
1.2
Well-being for Clinicians and Staff
Healthcare environment as a workplace is stressful to its workers. Post-occupancy

evaluations of four hospital gardens in California revealed that nurses and healthcare
workers are able to achieve pleasant escape and recuperate from stress by using the
gardens (Cooper-Marcus and Barnes, 1995). Providing windows with view also help
staff stay oriented with regards to time of day and weather condition, achieving better
well-being (Dellinger, 2010). Studies also showed that daylight penetration improves
nursing productivity (Rechel and McKee, 2008). In support of this, all wards in KTPH are
provided with window and view out.
1.3
Well-being for Family, Visitors and Public
Studies have shown that patient recovery and well-being are enhanced by social support
and family care (McCullough, 2010, p.82). As family members providing care and
support to the patient likewise experience stress and anxiety, it is important that their
well-being is also addressed. Post-occupancy studies have revealed that patients family
who use hospital gardens also experienced positive mood change and reduced stress, as
well as higher satisfaction with overall quality of care (Whitehouse et al., 2001).
176
Appendix VI (Contd)
1.4
The cost in healing gardens is relatively low as compared to healthcare equipment,

procedures and technologies. In addition, by speeding up patient recovery, it reduces the
cost of delivering healthcare services (Ulrich, 2002), hence also enhancing economic
sustainability. In addition, a 2004 CABE Healthcare report (2004) based on survey of
nursing clinicians found that external space is important to recruitment (p. 17), retention
(p. 22) and performance of nursing clinicians (p. 27). These suggest that access to and
integration of natural environment with healthcare environment contributes not only to
human wellness, but also economic sustainability.
The above benefits with support from evidence-based studies strongly suggest that
wherever possible, natural and landscape elements should be integrated into the design
of healthcare architecture, with KTPH being one example demonstrating such an
outcome.
1.5
Improves Way-Finding to Reduce Stress
Spatial disorientation causes stress, and as a result negatively impact patients healing
outcome and staff working in healthcare environment (Ulrich et al, 2004). The need to
give directional information by other than front desk information staff has also resulted
in hidden costs to many hospitals (ibid.). Integrated and holistic way-finding systems
help to reduce stress and economic loss related to way-finding.
In addition to providing greenery for human well-being, the central courtyard in KTPH
simplifies way-finding by enabling building users to relate to the lush central greenery
through external corridors and ample exterior windows from within the rooms (Figure
VI-4). Escalators and lift lobbies are also opened into the central courtyard, providing
users with a pleasant visual cue to orientation. Open circulation system are brightly lit,
and public furniture provided for activity and rest are placed to face the courtyard to
maximize its calming and healing properties.
177
Appendix VI (Contd)
Figure VI-3 Easy wayfinding: External corridors surrounding the Courtyard are brightly lit,
easy to orientate and laced with landscape to create a biophilic environment.
Source: CPG Consultants Pte Ltd)
Figure VI-4 Public furniture with good access to the Courtyard and Yishun pond views.
178
Figure VI-5 Courtyard at Ground level in Khoo Teck Puat Hospital is filled with lush sustainable
local plant types to achieve evidence-based supportive environment for patients, staff and visitors.
179
In integrated design, buildings arent seen as oneoff, independent entities made up of separate
building systems and isolated from their
surroundings but instead as part of a holistic
process, an interdependent, living part of the
environment into which it is placed and belongs."
Randy Deutsch
Appendix VII:
Energy-Efficient Active Design Measures
180
Appendix VII
VII. Energy-efficient active design measures

The estimated energy consumption for KTPHs proposed design is 36,059,410.23kWh per
annum, a saving of 36.4% as compared to the baseline reference model of
56,670,006.47kWh per annum (CPG Greenmark submission report). The following
energy-efficient active design measures were reportedly adopted in KTPH based on
CPGs Greenmark submission report.
1.0
Energy-efficiency air-conditioning system
KTPH was designed to be served by chilled water central plant room system with 5
numbers of 900Ton centrifugal chillers served with AHUs and FCUs. Heat recovery
systems were used to reduce energy loss. The individual efficiencies of the airconditioning system were as follows:
1. 900Ton Chillers:
0.49kW/Ton
2. Chilled water pumps:
0.080kW/Ton
3. Condenser water pump:
0.049kW/Ton
4. Cooling tower:
0.042kW/Ton (0.2205kW/L/Sec)
5. Plant room efficiency:
0.49+0.08+0.049 = 0.619kW/Ton
6. System efficiency:
0.49+0.08+0.049+0.042 = 0.661kW/Ton
The plant room efficiency was benchmarked against Singapore Standard SS530, under
which the minimum efficiency of the plant room was 0.782kw/Ton. The KTPH design
was hence 20.8% more efficient. Under SS530, the cooling tower efficiency was
0.31kW/L/s, hence the KTPH design was 28.8% more efficient.
2.0
Energy-efficiency lighting system
To conserve energy, high-efficiency T5 lighting with electronic ballasts was used for
general lighting, along with other high-performance, high-efficient lighting. The total
design wattage was 1,340.5kW compared to 1,463kW reference design, i.e. a saving of
8.4%.
181
Appendix VII (Contd)
3.0
Energy-efficiency carpark mechanical ventilation system
The mechanical ventilation system of the Basement 2 carpark is monitored with CO2
sensor. This conserves energy by ensuring that the mechanical ventilation system was
only turn on when required.
4.0
Natural ventilation to common areas
Wherever possible, the common areas were designed to ventilate passively, through
natural ventilation:
1. Staircase: 71% natural ventilation, 29% mechanical ventilation

2. Corridors: 30% natural ventilation, 1% mechanical ventilation, 69% airconditioning
3. Toilets: 100% mechanical ventilation
4. Atriums: 100% natural ventilation
5.0
Energy-efficient lifts and escalators
All lifts in KTPH utilise variable-voltage, variable-frequency (VVVF) motor drive to save
energy by matching the energy consumption with the system demand.
All escalators were embedded with motion/step-sensor to conserve energy when traffic
volume is low.
6.0
Energy-efficient practices and measures
Other energy-efficient features include the use of:
1. Heat pipe
2. Integrated building monitoring system monitoring measures
182
Water is essential to life. It is hygienic, aesthetic,

spiritual, life sustaining, and symbolic.
Stephen Verderber
Appendix VIII: Water-Efficient Considerations
183
Appendix VIII
VIII. Water-efficient considerations

The following water-efficient measures were reportedly adopted in KTPH based on
CPGs Greenmark submission report.
1.0
Efficient water fixtures & fittings
Water efficient fittings rated based on Singapore Public Utilities Boards (PUB) Water
Efficiency Labeling Scheme (WELS) were used. Most of the fittings were rated as
excellent, as follows:
2.0
Fittings with Excellent rating: 2,085 units (59.9%)
Fittings with Very Good rating: 733 units (21.0%)
Fittings with Good rating: 23 units (0.7%)
Fittings without rating (mostly special medical equipment): 642 units (18.4%)
Water usage and leak detection
Water meters were installed to monitor the portable water usage. The water meters were
linked to Building Management System (BMS) for intelligent monitor.
3.0
AHU condensate water is recycled to be used for cooling towers
Condensate water from AHU was collected and used as cooling tower make-up water.
Besides helping to reduce the amount of make-up water needed, the lower water
temperature of the condensate water also raises chiller efficiency.
4.0
Water Efficient Landscaping Irrigation System
Rainwater collected within the KTPH site was fed to Yishun Pond, adjacent to the site.
The raw water (non-portable) from Yishun Pond was used for landscape irrigation in
KTPH, to reduce consumption on potable water. Newater, water recycled from sewage is
used as a backup water source for the irrigation system.
184
Give all building occupants environmental comfort

and, most importantly, control over that comfort
this most obviously involves heat and light. However
it also includes sound. Hospitals are notoriously noisy
places. Some of Ulrichs research has shown that
patients in a cardiac unit had their heart rates
significantly reduced by decreasing background
sound levels. Giving patients bedhead controls of
lights, blinds, curtains and doors is really very cheap
to do and remarkably effective in reducing stress
levels.
Bryan Lawson
Appendix IX: Indoor Environmental Quality
185
Appendix IX
IX.
Indoor environmental quality
The following indoor environmental quality measures were reportedly adopted in KTPH
based on CPGs Greenmark submission report.
1.0
Thermal Comfort
The air-conditioned spaces were designed to allow for cooling load variations due to
fluctuation in ambient air temperature to ensure consistent indoor temperature for
thermal comfort. The indoor air temperature was designed to be within 22.5C and
25.5C with relative humidity of less than 70%.
2.0
Acoustic Comfort
With acoustic consultants advice, the ambient sound level of KTPH was designed to
between 40dB and 50dB in all occupant areas. The measures included were:
Walls, partitions and doors specified to STC 35dB, 40dB, 45dB and 50dB
standards, where appropriate;
Acoustic ceiling tiles specified to minimum noise reduction coefficient (NRC) of

0.5;
Check for test reports of materials acoustic properties;
All wall perforation and duct penetration sealed with approved details to prevent
sound bridge/leak;
Use low-noise ceiling fan for subsidised ward areas;
Conduct acoustic commissioning for critical areas.
186
Appendix IX (Contd)
3.0
Indoor air quality
UVC Emitters60 was installed in the supply air duct just after the cooling coil, to kill all
pathogens. This improved the indoor air quality and helps to keep the cooling coil clean.
A radiometer was used to monitor the performance of the UVC emitter.
The AHU coils were pre-treated with titanium dioxide (TiO2), an anti-bacteria, antiodour and self-cleaning agent to eliminate bacteria and mould growth in the cooling
coils. As a result, it reduced the need for cleaning, as well as risk of sick building
syndrome.
Figure VIII-1 Schematic diagramme of a typical AHU in KTPH, showing the locations of UVC
emitter, radiometer and CO2 sensor. Source: CPG Consultants Pte Ltd
UVC refers to a type of ultraviolet (UVC) energy. The "C" wavelength is the most effective
germicide in the UVC spectrum. UVC Emitters are devices that generate UVC rays to kill germs.
60
187
In the service of healing people, healthcare

institutions use a tremendous amount of energy,
the conventional production of which is associated
with public health hazards. Fortunately, solutions
exist to reduce and even eliminate this paradox,
while also reducing operating costs, enhancing
patient outcomes, and boasting staff productivity.
Alexis Karolides
Appendix X: Renewable Energy Systems &

Other Innovation Measures
188
Appendix IX
X.
Renewable Energy Systems & Other Innovation Measures
The following renewable energy ststem and other innovation measures were reportedly
adopted in KTPH based on CPGs Greenmark submission report.
1.0
Solar thermal system
Vacuum tube solar thermal system is utilised to generate the hot water usage
requirements of the hospital. The solar thermal system and solar heat pumps produce
was designed to fully meet the hot water requirements of the hospital (21,000 litres/day).
This resulted in a saving of 780kWh/day of electricity and the space for boiler was
eliminated.
Figure X-1 Vacuum tube solar thermal system in KTPH is used to generate hot water
2.0
Photovoltaic system
A 130kWp photovoltaic system, occupying a roof area of 1,200m2 is designed and

installed. It is estimated to generate approximately 150,000kWh of energy per year (See
Figure X-2).
189
Appendix IX (Contd)
Figure X-2 Photovoltaic system installed at the rooftop of KTPH to maximise solar exposure
and electricity output. (Source: CPG Consultants Pte Ltd)
3.0
Other Green and Innovative Features
3.1
Self-sustaining Ecological Pond
The water feature in Basement 1 of the courtyard was designed as an eco-pond,

essentially an ecologically self-sustaining pond that blended into the landscape. Besides
enhancing the environmental quality, it was also educational in promoting the concept
of sustainability.
The filtration of the Eco-pond was powered by a light mechanical pump. A diverse range
of marginal and water plants and small fishes form the eco-system, but only small fishes
were used, so that the system was able to handle the waste generated.
The water supply of the pond was from rainwater collected from the roof, filtered by the
roof garden. Excess water was fed to the water-efficient irrigation system.
190
Appendix IX (Contd)
Figure X-3 Eco-pond (Source: CPG Consultants Pte Ltd)
3.2
Other Innovative Green Features
Other green features that have been provided in KTPH were:
1. Dual refuse chutes for separation of recyclable waste.

2. Siphonic rainwater discharge system to reduce pipe size, hence reduce space
wastage, as well as to reduce noise.
3. Automatic waste and soft linen collection systems.
4. Auto tube cleaning system was used to reduce consumption by approximately
20%.
5. Composting machine was used to process food waste into fertilizer for roof and
food gardens.
191
If we are to understand and build upon the

integration between nature and human nature,
between the built and natural environments, we
need to rethink our attitude towards the practice of
design and of construction."
Appendix XI: Integrated Design during

Construction Phase
192
Appendix X
XI.
Integrated Design during Construction Phase
1.0
Placemaking
The integrated design effort continued even during construction. While the main
structure and architectural work was in progress, one of the areas of design focus for the
KTPH HPC and the building professionals was place-making in the social and
landscape spaces, so as to meet the objective of healthcare built environment as a socially
sustaining therapeutic environment. From a design coordination minutes dated 17 th June
2009, KTPHs COO Chew reiterated that the place-making is a process of creating a
natural gathering place with the right look and feel to put people at ease when they
come into the hospital groundsThe hospital grounds should offer a healing
environment for the patients family members to comfort each other. Spaces need to be
designed for events to happen (CPG file archive). CPG Architect Pauline Tan recounted
that more than twenty locations were identified, with provisions made for lighting,
power point and routing for cables, LAN, water point, audio system with pipe-in music
wherever possible, ventilation, thermal comfort (e.g. spot cooling of roof terraces
presented in Section 4.2.1) and acoustics, mobile art and banners etc.
Figure XI-1 Positive image of AH and nature in KTPH lift interior.
193
Appendix XI (Contd)
2.0
Interior Design
In interior design, artworks and images from the lush greenery in KTPHs previous
premise (AH) were displayed (Figure XI-1), to create positive, therapeutic impression
(verderber, 2010, p. 132). For example, the lit ceiling panel of the lift car. This again
demonstrated collaboration between the medical staff with intimate memory of AH and
building professional e.g. interior designers, M&E engineers and contractors.
3.0
Yishun Pond Community Project
The integrated, whole-system thinking went beyond the close collaboration between
medical and building professionals. Architect Lim recalled, During the construction of
the hospital in 2007, KTPH embarked on a community project to rejuvenate Yishun
Pond. At that time there was no budget for any landscaping works on the pond. KTPH
adopted the Yishun pond and convinced other government agencies through their
respective programmes, namely HDB (Remaking Our Heartland), NParks (routine
landscape programme), and PUB (ABC Waters) to co-finance the Yishun Pond
rejuvenation works for the community and patients. CPG Consultants and Peridian Asia
were also appointed to carry out an integrated landscape design involving multiple
agencies for the boardwalk, tower, overhead bridge and landscape around the Yishun
Pond that also connects well with the KTPH landscaped area. Though the hospital was
operational in 2010, the comprehensive healing environment was fully realized with the
completion of the Yishun Pond in 2011.61 In this instance, a positive, integrated outcome
for community benefits was achieved through a willingness to collaborate amongst the
governmental agencies, brought about by KTPHs CEO Liaks social influence and skills.
61
Interview session held in Jan 2012.
194
[G]reen building rating systems and other practice

tools are necessary as part of a buildings integrated
design process."
Marian Keeler and Bill Burke
Appendix XII: KTPHs BCA Green Mark Performance
195
Appendix XII
XII. KTPHs BCA Green Mark Performance

BCA Green Marks Non-Residential Building (NRB) Version 3.0 (GM NRB 3.0), part of
the Singapore national green rating system, was used as a tool to guide the green
building design for KTPH. It was certified as Green Mark Platinum in 2010, the highest
award under the BCA Green Mark Scheme. The assessment criteria of GM NRB 3.0 is
shown in Figure XI-1. It could be seen that energy efficiency is an important
consideration for GM NRB 3.0, requiring a minimum score of 30 points, while all the
other four criteria (water efficiency, environmental protection, indoor environmental
qualities and other green features) must achieve a minimum score of 20 points in order
to achieve the minimum score of 50 points, which is mandatory for Singapore since 2008.
KTPH achieved a score of 71.35 points for energy efficiency measures (Figure XII-2), out
of which GM NRB 3.0 accords a maximum of 50 points. The design consumes 36.4% less
energy then the baseline reference model. Under GM NRB3.0, the design also scored
maximum points for:
1. Building Envelope ETTV

2. Air-Conditioning System
3. Building Envelope Design/Thermal Parameters
4. Natural Ventilation
On the other hand, it scored a low 4.69 out of a total of 20 points (Figure XII-2) in the use
of renewable energy. Solar thermal for hot water and photovoltaic panel for electricity
were used in limited application, due to a need for budget management.
Maximum scores were also achieved for many other categories, including Greenery,
which is a main feature in KTPH. Categories where less than maximum scores were
achieved are: Water efficient fittings (6.08 out of 8), Sustainable Construction (4.5 out
of 14), and indoor air pollutants (1 out of 2). The score indicates that there are certainly
rooms for improvement in terms of sustainable construction.
196
Appendix XII (Contd)
Figure XII-1 BCA Green Mark Non-Residential Building Version 3.0 Assessment System.
Source: Building Control Authority (BCA), Singapore.
197
Appendix XII (Contd)
Figure XII-2 KTPHs BCA Green Mark Energy Efficiency Score under NRB 3.0 Scoring System.
Source: CPG Consultants Pte Ltd.
198
Passive Mode requires an understanding of the

climatic conditions of the locality, then designing
not just to synchronize the built forms design with
the local meteorological conditions, but to optimize
the ambient energy of the locality into a building
design with improved internal comfort conditions
without the use of any electro-mechanical systems."
Ken Yeang
Appendix XIII: Thermal Comfort Outcome of KTPHs

Bioclimatic and Natural Ventilation Strategies
199
Appendix XIII
XIII. Thermal Comfort Outcome of KTPHs Bioclimatic and

Natural Ventilation Strategies
The potential and challenges of harnessing natural ventilation as a passive design
strategy, in order to balance the various needs: reduce energy usage, health and safety
e.g. infection control, human comfort, and meeting policy requirements e.g. subsidized
patient wards, have been discussed in Section 1.5.1. Due to its benefits, natural
ventilation is an important ventilation strategy for public hospital in Singapore, with
65% of public hospital being naturally ventilated (Lai-Chuah, 2008).
In his dissertation, Wu (2011) conducted post-occupancy survey over three hospital with
ventilated wards, namely, KTPH, completed in 2010; AH, built more than 70 years ago in
1934; and CGH, built more than 14 years ago in 1997 (Wu, 2011). It was found that
patients in the air-conditioned (for private ward patients) and naturally ventilated (for
subsidized patients) wards had equally high acceptability of the thermal environment in
KTPH (Figure 3.16). Both CGH and KTPH met the ASHARE 55-2010 thermal
satisfaction requirement for their air-conditioned and naturally ventilated wards (ibid.
p. 71). With regards to nursing clinicians, Wus survey found that none met the ASHARE
55-2010 standard requirements, but KTPH provided conditions that satisfied more
clinicians (77.4%) then CGH (64.3%) and AH (30.8%)(Figure XIII-1; ibid, p. 76). Wu
attributed this to the higher activity level performed by nursing clinicians as compared
to patients (p. 104). KTPHs acceptability of 77.4% is also very close to ASHARE 552010s requirement of 80% acceptability.
Interestingly, Wu also found that there is insignificant difference in the satisfaction level
between patients in the naturally ventilated ward and the air-conditioned ward (Figure
XIII-2; Ibid., p. 101). This finding validated that with thoroughly considered bioclimatic
design, it is viable to design healthcare wards using NV, with ventilation at nurse station
enhanced by fan with localized control.
200
Appendix XIII (Contd)

Wu attributed the performance outcome of the KTPHs built environment to its
integrated sustainable design strategies, encompassing site planning, venturi effect of the
courtyard, landscaping, building shape and layout, building envelope, faade design,
central atrium, interior design, and partial energy recovery through recycling of cooled
air (Wu, 2011; Table XI-1).
Figure XIII-1 Patient acceptability of thermal environment in CGH and KTPH.

Source: Wu, 2011, pp. 71.
Figure XIII-2 Nursing Clinician Acceptability of Thermal Environment in CGH and KTPH.
Source: Wu, 2011, pp. 76.
201
Table XIII-1 Sustainable Design Strategies Employed in Khoo Teck Puat Hospital for Thermal
Comfort in Naturally Ventilated Area. Source: Wu, 2011, p. 130-131
202
Table XIII-1(Contd) Sustainable Design Strategies Employed in Khoo Teck Puat Hospital for
Thermal Comfort in Naturally Ventilated Area. Source: Wu, 2011, p. 130-131
203
Often, additional organizational social benefits is

achieved through an integrated design process that
engages a wide range of stakeholders, where the
building design is viewed as only one component
of an institution-wide environmental improvement
initiative that involves everyone.
Appendix XIV: Evaluating Human Wellness and Social

Sustainability of KTPH
204
Appendix XIV
XIV. Evaluating Human Wellness and Social Sustainability of

KTPH
1.0
Post-Occupancy Survey (Sng, 2011)
Through a post-occupancy survey, Sng P. L.s dissertation (2011) reported that besides
being a Green Mark Platinum certified green building, KTPH has provided for natural
and social environments well to a reasonably large extent (p. 74). From among sixteen
features, the most noted and welcome features of KTPH, in ascending order, are (Sng,
2011, p. 61; Figure XIII-1):
Figure XIII-1 Number of times being mentioned as a group description (constructs) and number of
times being chosen as a top priority group. Source: Sng, 2011, pp. 60.
205
Appendix XIV (Contd)

1.
Natural Scenery;
2. With Families and Friends in combination with Recreational Activities

3.
With Families and Friends in combination with Walking and Viewing
4. Relax which indicates the effectiveness of KTPHs premise as a healing

environment.
1.1
Natural Scenery
The integration of nature into the KTPH premise, an outcome due to the biophilic
approach taken by KTPH and its design team, was found by Sng62 to be the most welllike feature. It was also deemed to be the most important among all the features. In
addition, the survey also found that people prefer the positive feeling that nature offers,
rather than manicured gardens (Ibid., p. 67). This validates both the biophilia
hypothesis (Wilson, 1984; Kellert et al, 1993; Kellert, 2004; see also Appendix V), as well
as the KTPH CEO Liak Teng Lits personal belief. Based on CPG Architect Jerry Ongs
account, besides the aforesaid reason, Liak also believed that by using local plant types
in a natural setting, it require less intervention and efforts for the plant ecology to thrive.
This is not only more ecologically friendly, but results in lower maintenance as well
(Ong, interview session in Jan 12).
1.2
A Relax, Therapeutic Environment to Foster Social Activities
Social or communal activities are the next well like feature in KTPH, indicating that its
premise is well provided for people (Sng, 2011, p. 67). The association of its premise
with experience such as With Families and Friends, Recreational Activities, Walking
and Viewing and Relax may imply that people enjoy the premise as a social setting, as
supported by its natural environments. This appears to support the evidence-based
design principles with regards to well-being for family, visitors and public (Whitehouse
et al., 2001; see 1.3 in Appendix V) and well-being for clinicians and staff (CooperMarcus and Barnes, 1995; Dellinger, 2010; See 1.2 in Appendix V).
62
Sng used multidimensional scaling (MDS) to plot the data collected for interpreting the results.
206
1.3
Inadequacy of Green Mark Rating System
Sng also found that these wellness dimensions of World Health Organizations Quality
of Life (WHOQOL) are in fact missing from BCA Green Mark rating system (Ibid., p.
75). As a result, in focusing on technical performance of the built environment, Green
Mark is able to promote building design as a system of building sub-systems, but
inadequate to address social and ecological dimensions of sustainability. This is perhaps
not the current purpose of Green Mark rating system. Nonetheless, it also indicates that
the objectives-setting of such wellness dimensions would have been to be generated
independently from the Green Mark rating system; in the case of KTPH, it was through
the vision of the KTPH leadership and a systematic objective-setting exercise by
employing the Total Building Performance framework (See Section 3.3).
2.0
Fostering Sustainability through Community Stewardship
Section 1.6.2.2 presented the opportunities for a sustainable healthcare institution to

open up its premise to connect, engage and be enjoyed by its neighbourboods and
communities, and encourage community participation in environmental, social and
healthcare programmes. The connectivity created between KTPH, Yishun Pond and its
neighbourhoods has open up such opportunities, allowing volunteer services (Table
XIII-1), community, social and partnership programmes (Table XIII-2), partnership
programmes, etc to make use of KTPHs premise. Fostered by KTPHs biophillic, userfriendly public spaces and amenities, the increasing community participations since the
opening of KTPH in 2010 demonstrate its potentials in fostering social sustainability at
the community level.
207
Table XIV-1 KTPHs Volunteer Programme. Source: KTPH Website1

Activities around the Hospital
Patient Greeters
Help extend a warm welcome to visitors and assist them

with directions to the desired clinics / offices / wards.
Contact Centre
CALL-eagues
Assist call centre by answering simple queries and

extending the hassle-free experience beyond KTPH
premises.
Create a healing environment for patients by tending to
our gardens and organic rooftop vegetable farm.
Gardening Club
A&E Next of
Kin Counter
Ease the anxiety of relatives of patients who are in the

restricted A&E observation area. Provide updates and
help answer queries about the admission process.
Weekdays during office

hours, 2 hrs per session,
timing flexible.
Weekdays from 12 pm to 2
pm, Saturdays from 10 am
to 12 pm
Timing flexible, dependent
on weather. At least 2 hrs
per session.
Any day of the week,
timing flexible, 2 hrs per
session
Patient related Activities

Patient
Companions
Befrienders
Home-based
para
counselling
Inpatient
Mobile Library
Team
Accompany patients during their outpatient

appointments. Escort patients to the clinics and
pharmacy, provide a listening ear and help patients
understand instructions from healthcare workers.
Make weekly or bi-weekly visits to patients homes to
follow up on their progress, interact with them and
provide a listening ear.
Certified counsellors sought to provide assistance to
patients and caregivers at their homes via weekly or biweekly visits.
Read with inpatients by bringing KTPHs mobile library
of reading materials to them.

hours. Timing flexible,
dependent on patients
appointment time.
on patients availability.
on patients / caregivers
availability.
Any day of the week
9.30 am 11.30 am or
3.30 am 5.30 pm
Events & Logistics

Logistics/
Administration
Support the admin and operations departments through

tasks such as data entry and database management,
design of publicity materials, placement of posters and
signage for various events, wrapping corporate gifts,
packing corporate collaterals etc.
References:
1 http://www.ktph.com.sg/main/pages/1443 [online] <Accessed on 31.12.2011>.
208

hours, 3 hrs per session,
timing flexible.
For more than 99 percent of human history people

have lived in huntergatherer bands totally and
intimately involved with other organisms. During
this period of deep history, and still further back
they depended on an exact learned knowledge of
crucial aspects of natural history. . . . In short, the
brain evolved in a biocentric world, not a machineregulated world.
Edward Osborne Wilson
Appendix XV: KTPHs Environmental Stewardship
209
Appendix XV
XV. KTPHs Environmental Stewardship

By adopting an integrated approach in site planning, connecting the KTPHs
environment with Ponggol Pond and the Yishun natural and community context, the
design opens up opportunities for community and environmental stewardship for
KTPH, as discussed in Section 1.0 to 3.0:
4. Maximizing opportunities in creating a biophillic built environment (Section 1.0).

5. Integrating with Yishun Pond environmentally and socially (Section 2.0).
6. Fostering biodiversity (Section 3.0).
1.0
Some Yishun residents, including retired farmers in the Yishun community (Wu, 2011, p.
108) had volunteered to tend to the rooftop vegetable and fruit gardens at KTPH (AHa!
Mar-Apr 2010, p. 11; Figure XIV-1, XIV-2). One key volunteer with green fingers, 68-year
old Mdm Lim Chew Eng, who also tends to community farm in Yishun town, shared her
experience and help create an urban farm in the hospital (Ibid.). The produce such as
tomatoes, melons, and bananas (Wu, 2011, p. 107) is shared between volunteers and
the hospital kitchen, and composted food waste from the hospital kitchen provided
fertilizer for the crops (Ibid, p.107). KTPH reported that:
KTPHs Chief Gardener, Rosalind Tan, who oversees the volunteer gardeners
said that residents were keen to get involved and brought their friends along. She
welcomes them and others tooUrban farming on the rooftop not only provides
the hospitals kitchen with an organic food source for our patients, it also reduces
the temperature of the building and involves the community in caring for our
patients and the environment. (Alexandra Health Newsletter AHa! Mar-Apr
2010, p. 11)
210
Appendix XV (Contd)
Besides vegetable gardening, many other biophilic features including therapeutic

gardens, patios, balconies, terraces (Figure XIV-4), courtyards (Figure XIV-3), and water
as therapeutic modality (Figure 3.3, 3.18, 3.19), etc that Verderber (2010) has
recommended for the hospital environment, with KTPH providing some examples.
Figure XIV-1 Rooftop vegetable gardens at Khoo Teck Puat Hospital

Figure XIV-2 Yishun resident volunteers led by Rosalnd Tan (Second from right) working on the
Urban Farm above KTPH. Source: Alexandra Health Newsletter AHa! Mar-Apr 2010, p. 11
211
Appendix XV (Contd)
Figure XIV-3 Interrelationships of gardening in semi-open space, people and climate in tropical highrise housings. Source: P. Kong in Bay and Ong, 2006, p. 75.
In his thesis, Kong (2005) suggests that gardening, people, and environment form a
triangle of interrelationshipswhere one stimulates the other (Bay and Ong, 2006, p.
75). As participants tend to the KTPH urban farm with care and interest, creating a sense
of community ownership, the plant in turn improve the environment, the activity
increases, improving the casual knowing of neighbours and sense of community, and
thus in turn encourage more interest in gardening [and/or farming](Ibid., p. 75). Nature
and community henceforth develops a symbiotic relationship.
Figure XIV-4 Rooftop gardens, balconies, patios at KTPH help reduce the indoor temperature and
mitigate urban heat island effect. Source: CPG Consultants Pte Ltd
212
Appendix XV (Contd)
2.0
Integration with Yishun Pond
KTPH adopted the Yishun pond in 2005 under Public Utilities Board (PUB)s Our
Waters Programme, and participated actively in plans to transform it into a green lung,
e.g. organizing regular pond clean-ups of areas around the pond (AHa! Sep-Oct 2010, p.
2)63. With the opening of KTPH, through a collaboration between National Environment
Agency (NEA), PUB, National Parks Board (NPB) and Alexandra Health (KTPHs
holding company), improvement work was carried out at Yishun Pond to turn it into an
intergenerational, health promoting garden that will be integrated with the hospital
(Ibid.).
It provided more and better park facilities for residents living in the surrounding Yishun
communities to exercise and interact. Marshlands created along the shore softens the
water edge and improve water quality by filtering pollutants through the use of aquatic
plants, as well as attracting wildlife and enhancing biodiversity. A barrier-free lakeside
promenade was built to connect KTPHs central courtyard to the garden (Ibid.),
providing more opportunities for KTPH to spread health promoting messages among
patients and Yishun residents (Ibid.).
PUBs Active, Beautiful, Clean Programme (ABC) launced in 2006 is a strategic

initiative to improve the quality of water and life by harnessing the full potential of our
waterbodiesby integrating the drains, canals and reservoirs with the surrounding
environment in a holistic way (ABC Guidelines, p. 4). Under the ABC programme, built
environment that harness water sensitive urban design and sustainable drainage
principles may be ABC certified, and KTPH is ABC-certified in 2010. The following
reasons were cited (PUB):64
1. Planter boxes and green roofs detain and treat 12% of rain water run-off that is
harvested for reuse.
63
64
Alexandra Health Newsletter, AHa! Sep-Oct 2010, p. 2

PUB Website: http://www.pub.gov.sg/abcwaters/ABCcertified/Pages/2010.aspx#a6
213
Appendix XV (Contd)
2. A green wall and terraced landscape enhances the lushness of the area while
resting and seating facilities along streams and water features bring people closer
to water.
3. Integration with the nearby Yishun Pond, with extensive plantings providing a
tranquil and scenic environment for the hospitals patients and visitors while
creating a suitable habitat for birds and butterflies.
4. Collaborates with schools and institutions in programs such as Earth Day to
spread educational messages.
3.0
Fostering Biodiversity
Sustainable development and the preservation of biodiversity are important
components of KTPHs environmental philosophy. Vast areas of KTPH have
been earmarked for landscaping and planting to encourage the creation of
habitats and a healthy environmental ecosystem. (KTPH) 65
The core KTPH management and team migrated from Alexandra Hospital (AH), 66
including Rosalind Tan, KTPHs Chief Gardener. As reported (TODAY, 2007), 67 she
was a senior executive at AHs operations department, and since 2000, she has led the
AH team in transforming 12 hectares of the hospital grounds, bringing in 500 species of
trees and shrubs, aromatic flowers, water features even a butterfly trail that boasts 100
species. (Ibid.) For her contributions towards environmental sustainability, she was
awarded the inaugural EcoFriend Award by the National Environment Agency.
AHs garden is popular on weekends, with former patients bringing their families there
for a stroll, and members of nature societies using it as a study ground (Ibid.; Table XV1)
KTPH Website: http://www.ktph.com.sg/main/explore_ktph_pages/232

See History of Alexandra Hospital. In: Alexandra Hospital Website. [online] Available at:
<http://www.alexhosp.com.sg/index.php/about_us/our_history> [Accessed 31.12.2011]
67 See Chang, C. (2007). Solace in the hospital grounds. In Channel News Asia Website. [online]
Available
at:
<http://www.channelnewsasia.com/stories/singaporelocalnews/view/282365
/1/.html> [Accessed 31.12.2011]
65
66
214
Appendix XV (Contd)
Table XV-1 Nature Activities and Reports of Alexandra Hospitals garden and butterfly sighting.
Date.
Event
30.07.2005
Perry, M. Alexandra Hospital opens new garden of medicinal plants. Channel News Asia
(http://www.wildsingapore.com/news/20050708/050730-1.htm#cna1)
Perry, M. Alexandra Hospital garden has plants that heal, thrill or kill. Channel News
Asia (http://www.wildsingapore.com/news/20050708/050730-1.htm#cna1)
Baron, G. Locally Extinct Butterfly Sighted at AH! Singapore Nature Society Butterfly
Interest Group (http://bignss.blogspot.com/2008/03/new-species-sighted-atalexandra.html)
Wong, W. Euphorbia in Bloom @ Alexandra Hospital & Other Happenings. Garden with
Wilson (http://gardeningwithwilson.com/2008/04/04/euphorbia-in-bloomalexandra-hospital-other-happenings/)
Khew, S. K. Butterfly Photography at our Local Parks. Butterflies of Singapore
(http://butterflycircle.blogspot.com/2008/07/butterfly-photography-at-ourlocal.html)
Commander. Shooting at Alexandra Hospital Butterfly Trail. Butterfly Circle
(http://www.butterflycircle.com/?p=17)
Wong, W. Alexandra Hospitals Garden Party. Garden with Wilson
(http://gardeningwithwilson.com/2008/11/12/alexandra-hospitals-garden-party/)
Mantamola. Butterfly Park @ Alexandra Hospital. Manta blog
(http://mantamola.blogspot.com/2009/02/butterfly-park-alexandra-hospital.html)
National Parks Board. Creating Butterfly-Friendly Habitats.
(http://www.nparks.gov.sg/cms/index.php?option=com_content&view=
article&id=172&Itemid=129)
ItchyFingers. A Visit to the Hospital.
(http://myitchyfingers.wordpress.com/2009/12/05/a-visit-to-the-hospital/)
Seah, J. Alexandra Hospital Butterfly Trail, S'pore. Singapore Fauna and Flora
(http://www.flickr.com/photos/j_for_joyce/sets/72157623471951042/)
Khew, S. K. and Tan, E. Return of a Magnificent Giant. Butterflies of Singapore
(http://butterflycircle.blogspot.com/2011/03/return-of-magnificent-giant.html)
Lim, S. et al. Alexandra Hospital Butterfly Trail. Informal Macro Outing Group
(http://npssimog.blogspot.com/2011/04/82011-alexandra-hospital-butterfly.html)
Starmer, C. F. Adventures with curiosity and learning.
(http://frank.itlab.us/photo_essays/wrapper.php?jul_22_2011_ahbt.html)
Gan, W. C. Singapores Winged Wonders. Singapore Kopitiam
(http://www.singaporekopitiam.sg/places-and-heritage/places/wildlife-andnature/item/1001-singapores-winged-wonders)
Mariano, M. Hospital Butterfly Trail. (http://flickeflu.com/set/72157626141292182)
Wong, C. P. Alexandra Hospital Butterfly Garden
(http://www.pbase.com/gohorses/alexandra_hospital_butterfly_garden)
Regular guided walk at AH by Butterfly Interest Group
(http://butterfly.nss.org.sg/home/butt_walks.htm)
16.10.2005
20.03.2007
04.04.2008
27.07.2008
28.07.2008
12.11.2008
15.02.2009
28.05.2009
29.05.2009
05.12.2009
16.02.2010
31.03.2011
02.04.2011
22.07.2011
30.11.2011
12.02.2012
Unknown
Unknown
215
Appendix XV (Contd)
The success of AHs butterfly trail was by no means an accident. According to a life-long
butterfly enthusiast based in Singapore (Khew, 2008)68, it was a project started in 2002 led
by Rosalind, an occupational therapist who had drawn from her experience that a
butterfly garden could help in a patient's recovery, validating the biophilia hypothesis
and evidence-based studies on positive distraction (Lahood and Brink, 2010, Delinger,
2010):
Butterflies have so many colours and patterns. Seeing them gives patients
optimism and distracts them from their illnesses,' she said (Khew, 2008)
Vast areas of KTPH were earmarked for landscaping to encourage the creation of
habitats and a healthy environmental ecosystem. The hospital planning committee
sought to increase the indigenous wild life biodiversity by introducing native species of
plants in the hospitals landscaping. (Wu, 2011, p. 109) with life-long passion from staff
member like Rosalind Tan, its environmental philosophy and stewardship looks likely to
bring new success, as the management had set a biodiversity target for KTPH:
100 species of butterflies, birds, fishes, flowering plants, fruit trees, native trees,
edible plants and fragrant plants. Yes, all 800 of them (Ong, J, 2010)69
Such ambitious objectives are not likely to be set without a collective will driven by a
collective, shared vision and mindset of environmental stewardship, as suggested by
Batshalom and Reed (see Section 2.3.2 and Figure 2.3). To succeed, however, it also
necessitates a process of value sharing and transfer, from KTPH to the building
professionals, to ensure that the design of the built environment outcome supports such
vision. This is presented in Chapter 3 of the dissertation.
Khew, S. K. aka Commander, leads the butterfly interest group Butterflies of Singapore. He is
also this authors colleague in CPG. Source: http://www.butterflycircle.com/forums/
showthread.php?t=6993
69 Ong, J is the architect involved in the KTPH Project. Source: http://blog.cpgcorp.com.sg/?p=69
68
216
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I)
Chapter Page Quotations
Chapter 1:
Upper: Schettler, T. From Medicine to Ecological Health, in: Guenther, R., Vittori, G.
(2008), Sustainable Healthcare Architecture, John Wiley & Sons, New Jersey, p. 68
Lower: Guenther, R., Vittori, G. (2008), Sustainable Healthcare Architecture, John Wiley &
Sons, New Jersey.
Chapter 2:
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Guenther, R., Vittori, G. (2008), Sustainable Healthcare Architecture, John Wiley &
Sons, New Jersey, p. 133.
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Chapter 4:
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Sons, New Jersey, p. 154.
Lower: Berkebile, B. In: Guenther, R., Vittori, G. (2008), Sustainable Healthcare
Architecture, John Wiley & Sons, New Jersey, p. 19.
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Architectural Press, Oxford, p. 18.
Appendix II: 7Group, Reed, B. (2009), The Integrative Design Guide to Green Building:
Redefining the Practice of Sustainability, John Wiley & Sons, New Jersey, p. 68.
Appendix III: Krygiel, E. and Nies, B. (2008), Green BIM: Successful Sustainable Design
with Building Information Modeling, Wiley Publishing, Indianapolis, p. 32.
Appendix IV: Krygiel, E. and Nies, B. (2008), Green BIM: Successful Sustainable Design
Appendix V: Batshalom , B. In: 7Group, Reed, B. (2009), The Integrative Design Guide to
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Briefing: Hospital Engineering & Facilities Management, Issues 2, p. 27.
Appendix VII: Deutsch, R. (2011), BIM and Integrated Design: Strategies for Architectural
Practice, John Wiley & Sons, New Jersey, p. 138.
Appendix VIII: Verderber, S. (2010), Innovations in Hospital Architecture, Routledge,
New York, p. 52.
Appendix IX: Guenther, R., Vittori, G. (2008), Sustainable Healthcare Architecture, John
Wiley & Sons, New Jersey, p. 119.
Appendix X: Karolides, A. Energy Use, Energy Production, And Health. In: Guenther,
R., Vittori, G. (2008), Sustainable Healthcare Architecture, John Wiley & Sons, New
Jersey, p. 286.
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Appendix XI: Krygiel, E. and Nies, B. (2008), Green BIM: Successful Sustainable Design
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Sustainable Building, John Wiley & Sons, New Jersey, p. 231.
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Ong, B. L. (2006), Tropical Sustainable Architecture: Social and Economic Dimensions,
Architectural Press, Oxford, p. 53.
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Wiley & Sons, New Jersey, p. 119.
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Press, Washington, p. 32.
230

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The Practice of Integrated Design:

The Case Study of

Tan Shao Yen

31st January 2012

A dissertation submitted in partial fulfillment of the regulations for the Degree of

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

Background and Context of Healthcare Architecture ......................................................... 14

Scope and Objectives ................................................................................................................ 16

Research Questions ................................................................................................................... 17

The Key Challenges of Healthcare Architecture in Singapore ........................................... 19

Challenges Related to the Provision of Medical Services .................................................... 19

Challenges Related to Healthcare Organization, Structure and Culture ........................... 20

Sustainable Healthcare Architecture in Singapores Context ............................................. 21

Economic Sustainability ........................................................................................................... 22

Social Sustainability .................................................................................................................. 24

1.6.2.1 The Relationship between Human Wellness and Environment ........................................ 24

Environmental Sustainability .................................................................................................. 26

Defining Sustainable Healthcare Architecture ..................................................................... 30

Discussion: The Need to Integrate Inter-Disciplinary Knowledge .................................... 31

Chapter 2.0: The Integrated Design Approach...................................................................................... 33

The Definition of Integrated Design Approach .................................................................... 34

Benefits of the Integrated Design Approach in Healthcare Architecture ......................... 35

Increasing Scale & Complexity ............................................................................................... 36

Failure of Traditional Siloed and Linear Design Process .................................................... 36

The Integrated Design Process ................................................................................................ 37

Achieving Sustainable Healthcare Architecture ................................................................... 38

Learning Organization ............................................................................................................. 39

The Multi-Disciplinary Project Team ..................................................................................... 40

Integrated Design Process ....................................................................................................... 44

2.3.3.1 Team Formation and Organization ........................................................................................ 46

Tools and Techniques that Support Integrated Design ....................................................... 55

2.3.4.1 Integrated Design Tools ........................................................................................................... 55

Integrated Design Products: Sustainable Healthcare Architecture .................................... 60

KTPHs Site Context ................................................................................................................. 64

KTPH Visioning, Objective Setting and Briefing Process ................................................... 68

Methodologies: Focused Group Discussions and References ............................................ 68

The Shared Visions ................................................................................................................... 69

Setting the Objectives ............................................................................................................... 71

KTPH Team Formation and Organization ............................................................................ 75

The role of IDP Facilitator ........................................................................................................ 76

The role of the Prime Consultant Team ................................................................................. 79

The role of the Green Consultant ............................................................................................ 80

The role of User Groups ........................................................................................................... 80

The role of the Contractor ........................................................................................................ 81

Discussion: KTPHs Visioning, Objective Setting and Team Formation ........................... 81

Chapter 4.0: KTPHs Integrated Design Process ................................................................................... 83

The Process Map ....................................................................................................................... 84

DC: Design Competition (Prelim) .......................................................................................... 85

W1: Visioning Workshop ......................................................................................................... 87

W2: Masterplanning Workshop .............................................................................................. 87

MP: Schematic Design Research/Analysis/Design Process ................................................. 87

SD: Schematic Design ............................................................................................................... 88

VE1: Value Engineering Workshop ........................................................................................ 88

DD1 & DD2: Design Development ......................................................................................... 89

VE2: Value Engineering Workshop ........................................................................................ 90

The Practice of Workshop/Design Charrette ........................................................................ 90

Hospital Planning Committee Meetings that were held monthly ..................................... 91

The Iterative Process................................................................................................................. 92

Schematic Design (SD) Stage ................................................................................................... 93

The Design Development (DD1) Stage .................................................................................. 99

The Component Design (DD2) Stage ................................................................................... 107

Discussion: KTPHs Integrated Design and Iterative Process .......................................... 116

Chapter 5.0: Conclusion ......................................................................................................................... 118