General Hospital Building Guidelines - Netherlands

THE GENERAL HOSPITAL
BUILDING GUIDELINES FOR NEW BUILDINGS
(reportnumber 0.107)
Adopted by the Netherlands Board for Hospital Facilities on 7 October 2002
Approved by the Minister for Health, Welfare and Sports on 19 November 2002
General hospital building guidelines
CONTENTS
1. INTRODUCTION 1
2. GENERAL PRINCIPLES AND PRECONDITIONS 2

2.1 Principles 2
2.2 Preconditions 2
2.3 Supplementary areas 2
3. BASIC PRINCIPLES IN RELATION TO CARE 4

3.1 Upscaling 4
3.2 Specialist medical care 4
3.3 Organisation of care 4
3.4 Differentiated care 8
3.5 Design of the general hospital building guidelines 9
4. BASIC QUALITY REQUIREMENTS 11

4.1 Introduction 11
4.2 Reachability 11
4.3 Access 11
4.4 Flexibility 12
4.5 Spatial relationships 13
4.6 Quality of the environment 14
5. ARCHITECTURAL CONCEPTS 15
5.1 Introduction 15
5.2 Breitfuss model 16
5.3 Double comb structure 17
5.4 Arcade structure 19
5.5 Cross structure 20
5.6 Branched structure 22
5.7 Linear structure 24
5.8 Pavilion structure 26
6. FINANCIAL ASPECTS 29
6.1 Building development investment costs framework 29
6.2 Practical application 30
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1. INTRODUCTION
These building guidelines concern the spatial facilities for a general hospital with basic quality
requirements at the level of the hospital as a whole. Together with the basic quality requirements
incorporated in the specific guidelines for specific functions of a hospital, they form the complete set of
basic quality requirements with which building plans for new hospitals have to comply.
The building guidelines were adopted by the Netherlands Board for Hospital Facilities (Bouwcollege) in a
resolution passed on 7 October 2002, taking into account article 15a of the Hospital Provision Act
(WZV), and approved by the Minister for Health, Welfare and Sports on 19 November 2002.
As appendix 1.01, the guidelines form part of the Hospital Provision Act Building Standards Regulations.
Please refer to the general section of the explanatory notes to the Netherlands Board for Hospital
Facilities Regulations ‘General Hospital Building Standards’.
In the Building guidelines Care Sector brochure, there is a description of the use of the guidelines and
how they were developed. This brochure can be ordered from the Netherlands Board for Hospital
Facilities. It can also be downloaded via the Board’s website: http//:www.bouwcollege.nl, where you will
not only find these guidelines but also the specific guidelines for specific functions of a hospital, as well
as other relevant publications.
Chapter 2 deals with the general principles and preconditions when compiling and applying the building
guidelines.
Chapter 3 gives the basic principles related to care that form the foundation of the guidelines, based on
evaluation and experience.
Chapter 4 describes the basic quality requirements at the level of the hospital as a whole.
Chapter 5 includes various architectural concepts with an explanation of how the basic quality
requirements described in chapter 4 have been or will be incorporated in the building structure of a
hospital.
Chapter 6 deals with the spatial and financial conditions related to building a new hospital.
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2 GENERAL PRINCIPLES AND PRECONDITIONS
2.1 Principles
Building guidelines
Building guidelines are a tool to help prepare building initiatives in the healthcare sector. They also form
an evaluation framework for the architectural and functional assessment of building applications
submitted by institutions.
Building guidelines not only provide a description of the minimum space needs and functional
requirements with which new care facilities have to comply. They also represent a reaction to
developments in the healthcare sector in recent years and, where possible, provide a picture of
developments in the immediate future (chapter 3).
Building guidelines comprise two parts: basic quality requirements and cost norms.
Basic quality requirements

The Basic Quality Requirements describe the minimum requisite level of quality with which certain
facilities or accommodation must comply in terms of functionality, safety and hygiene, whereby a
distinction can be made between “closed” and “open standards”.
The term “closed standards” refers to standards that are clearly quantifiable. In the case of hospitals,
this may refer for example to minimum dimensions of patient rooms or spatial and technical
requirements for operating theatres and laboratories.
“Open standards” mainly consist of generally endorsed guideline criteria that are difficult to quantify. As
a rule, these “open standards” refer to aspects that particularly play a role at a level of the hospital as a
whole, such as the flexibility of the building structure or the quality of the built environment.
Chapter 4 goes deeper into the above-mentioned basic quality requirements.
Cost norms
The guidelines have been flexibly designed so that, given the basic quality requirements, various
solutions are possible within specific frameworks. With respect to the building of WZV Hospital Provision
Act facilities, these frameworks are principally determined by maximum permissible investment costs.
Chapter 6 describes how this investment cost framework is determined and how it is applied in practice.
Scope
Appendix 1 states for which hospital functions the basic quality requirements (will) apply. The basic
principle in this respect is that only the patient-related functions of a hospital will be applicable for this,
such as nursing, diagnostics and treatment and medical supporting facilities (laboratories, pharmacy,
central sterile supply department). With regard to the other, usually general and technical supply
facilities, no basic quality requirements will be imposed with the exception of the kitchen facilities. It is
this aspect that gives the standards their flexibility.
2.2 Preconditions
When drawing up the guidelines, account was taken of regulations relating to environment legislation
and regulations applicable to building in general. Examples include the Buildings Decree (relating to
storey height, daylighting and ventilation regulations etc.), the Building Access Handbook (wheelchair
access), the Working Conditions Act (relating to the use of sling hoists etc.) and the Tobacco Act (that
states that patients and staff must be able to function without hindrance caused by the use of tobacco
products).
2.3 Supplementary areas
The above-mentioned guidelines are limited to facilities for functions that a care provider must or can
provide. During realization of these facilities, it may be necessary to pay attention to other aspects that
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are either related to or a consequence of the building activities. Examples of this include acquisition of
land, site size, parking facilities, interim facilities or technical installations.
Attention is paid to these aspects in other publications of the Netherlands Board for Hospital Facilities
(http://www.bouwcollege.nl). In instances where these publications may be of relevance, reference is
made to them in this text.
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3. BASIC PRINCIPLES IN RELATION TO CARE
3.1 Upscaling
Since the nineteen seventies, there has been a trend towards upscaling. This is due to a number of
causes. On the one hand, developments in the field of the medical profession as such, for example
increasing specialisation, quality requirements laid down by the professional associations and the
introduction of expensive medical technology, lead to upscaling. On the other hand, government policy
has encouraged concentration. From the mid-seventies, policy aimed at reducing the number of beds
has led to amalgamation with new buildings as a survival strategy for the smaller hospitals. From the
mid-eighties, mergers took place on the basis of strategic considerations, in anticipation of the
announced introduction of market efficiency in the healthcare sector. Furthermore, the hospital budget
included a ‘merger premium’. This referred to the premium related to the scale based on the assumption
that large hospital in principle treats more complex patients, due to having a more extensive range of
functions.
This upscaling led to a decline in the number of hospital organisations, but not to an equivalent reduction
1
in the number of hospital locations . In order to maintain access to hospital care for the general public
as far as possible and also for strategic marketing reasons (retention of market share), amalgamated
hospital organisations often opt to keep locations open and divide functions differently over the
locations. Complex care and relatively expensive facilities such as general intensive care and cardiac
care consequently tend to be concentrated.
3.2 Specialist medical care
Developments in medical knowledge and science (applicable to healthcare) have led to extensive super-
specialisation and sub-specialisation of physicians, as a result of which the need for intra-disciplinary
cooperation has radically increased.
Developments in concepts about hospital care and care organisation, in which the wishes of patients are
now playing an important role, have created a need for interdisciplinary cooperation to grow. Sub-
specialisation, part-time work and the quality requirements of professional associations (that are often
also applied by the Inspectorate) have led to larger partnerships. The increasing juridification of the
primary process also has an impact on the development of the quality requirements of the professional
associations: patients have an increasing tendency to go to court. In addition, the scarcity of medical
staff can also result in concentration.
Nor has medical technology stood still. This has led on the one hand to the necessary concentration of
hospital care because it is only at a certain scale and production level that very expensive equipment
can be efficiently used, while on the other hand medical technology has also enabled medical specialists
to function on a small-scale. ICT has naturally made an important contribution to all of this, at both
diagnostic and therapeutic levels and at a communication level.
3.3 Organisation of healthcare
Until a few years ago, organisation of healthcare was largely based on the perspective of the medical
specialisations available in a hospital and the availability of diagnostic and treatment facilities.
Furthermore, due to the largely monodisciplinary approach to the patient’s care requirements, virtually
every specialisation had its own beds in the ward unit and diagnostic and treatment facilities in the
outpatient unit.
As a result of the developments in specialist medical care described in § 3.2 together with the fact that,
due to an increasing shift from inpatient to outpatient care and day treatment, inpatient care is being
1
Netherlands Board for Hospital Facilities: Feasibility study on desired distribution of hospitals 7 November 2000
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increasingly reserved for complex and difficult medical cases, attention has been paid in recent years to
a more integrated organisation of healthcare, based on the patient’s perspective.
This trend has led to a reorientation regarding the way in which the demand for hospital care is offered.
This reorientation process concerns the logistic process in both the hospital organisations and the entire
care chain. In broad terms the following categories may be distinguished. Although these display
similarities, a different emphasis may be placed on a number of aspects with regard to the organisation
of the care.
It is consequently also possible to combine the different planning models. The choice and detailing of
the organisation of the care is dependent on the situation and is largely determined by weighing up the
interests of the patient and the care provider in relation to management (scale size).
Planning on the basis of target-groups/clinical entities
The basis of this model is clustering activities as far as possible around the treatment of the patient,
whereby a distinction is generally made according to care units and supporting units.
The care units concern the primary process, patient care. This is based on grouping the different
specialisations present in the hospital, aimed at achieving a more or less comprehensive range of care
for patients with similar clinical entities.
Classification into care units/themes depends on the care profile of a hospital, whether or not certain
specialisations are present, the scope of the existing specialisations and the hospital’s policy and
profiling. Examples of care units/themes include ‘mother & child’, ‘oncology’, ‘brain & sense organs’ and
‘heart & vascular’.
The supporting units are focused on medical and general & technical support for the primary process.
Medical support includes imaging diagnostics, general organ function investigation, the pharmacy and
the laboratories. General & technical support mainly comprises facilities for management, such as
administration and provision of information, central kitchen, technical service and personnel facilities.
In practice, it is shown that the functional and spatial planning of the above-mentioned units can be
tackled in different ways.
Some projects have opted to combine inpatient and outpatient activities within one care unit, with the
incorporation of medical supporting functions. Other projects on the other hand have chosen a more
traditional form of planning in which a greater distinction is advocated between inpatient and outpatient
care and diagnostics. In this situation, the care process around the patient is generally based on the
principle of virtual multidisciplinary cooperation. These are forms of cooperation that are not
recognisable in a physical sense. The medical specialists work together around one patient group but do
not have office visits at the same time at one location. It is determined by means of protocols in what
manner the different specialisations and medical supporting facilities are used in the treatment of the
patient group.
Theme 1: Brain & sensory organs

Theme 2: Oncology
Theme 3: Immune system, metabolism & aging
Theme 4: Acute care & musculoskeletal system
Theme 5: Heart & vascular
Theme 6: Growth, development and reproduction
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Source: Erasmus MC Rotterdam
Planning on the basis of patient flows
In this model a distinction is made between four patient flows: acute care, urgent care, elective care and
chronic care. The underlying principle of this subdivision is the assumption that each patient flow
basically differs from the other in terms of atmosphere, organisation, planability, position of
professionals, relationship with referrers and follow-up care and the building aspect.
The acute care unit only deals with patients who are in a truly life-threatening situation. This is in fact a
well-equipped emergency department where mainly patients with severe trauma and injury are treated.
The urgent care unit deals with patients in cases where a few hours between registration at reception
and treatment will not lead to problems. With urgent care there is time between registration and carrying
out diagnostic procedures and treatment. This time is used to gather information about the patient, to
prepare the treatment plan within the hospital or arrange any follow-up care. A large proportion of the
patients who are currently (wrongly) admitted to the emergency care unit will be treated in the urgent
care unit. An observation unit forms part of the urgent care unit. The purpose of the urgent care unit is to
relieve pressure on the adjacent acute care unit (emergency department) as far as possible.
Elective care concerns care when there is a period of time (days, weeks) between registration and an
appointment. Elective care can usually be well planned. In order to safeguard this planability, it is
necessary to determine what has to be achieved with each patient target-group (the objectives).
Agreements are made between general practitioners, medical specialists, patient associations and other
parties involved about admission waiting-time, total treatment time, allocation of tasks and responsibility.
Chronic care concerns care where a long-term relationship with the patient is required. This type of care
demands a strong personal contact in a relaxed, non-hospital-like atmosphere. A great deal of attention
is paid to providing information and counselling to the patient, relatives, other parties concerned and the
referrer. Examples of chronic care are patients with heart failure, back problems, lung/asthmatic
conditions and diabetics.
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Source: Deventer Hospitals
Planning on the basis of the care process
This model is largely based on the stages through which a patient passes from the moment the patient
arrives in the hospital until the moment he/she leaves it. Six main processes may be distinguished here,
as follows:
• treatment from the general practitioner, resulting in referral;
• screening and diagnostic procedures;
• appointment with the specialist(s) to discuss the diagnostic results, advice, treatment possibilities
and treatment planning;
• treatment in different forms;
• care in different forms;
• aftercare in different forms.
Grouped around these main processes are ICT, the organisation and the facilities, resulting in six
different centres:
1. the centre for screening and diagnostics where investigations can be carried out;
2. appointment centre where consultations take place;
3. the treatment centre where treatment is carried out;
4. the nursing centre where nursing takes place;
5. the logistics centre from which support is given to the above-mentioned centres;
6. the knowledge/expertise centre where the professionals (in the broadest sense of the word) have a
place to work and meet each other.
This model is based on the assumption that modern ICT techniques are applied, aimed at integrated
planning of the care process – not only in the hospital but also outside.
The basic principle is that professionals in the care chain must be able to consult all information
independent of time and place. This means that all information must be digitally available.
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Source: Orbis Sittard
3.4 Differentiated care

2
The developments described above have led to a wide variety of forms of hospital care , such as:
• general practitioner centres in hospitals;
• the external outpatient unit that provides outpatient care during office hours (an independent
treatment centre can fulfil this description);
• the day hospital that provides general, specialist medical care that is not too complex, but where no
24-hour care is provided (an independent treatment centre can fulfil this description);
• the specialised hospital that concentrates on certain sections of hospital care or certain target-
groups and where 24-hour care and/or day nursing is provided;
• the general hospital where a distinction can be made between a basic hospital and a top clinical
hospital/intervention centre;
• the university teaching hospital.
The above-mentioned forms of hospital care occur in different organisation forms, varying from
independently operating entities to a combination of facilities under one hospital organisation or in a
cooperative organisational form.
Appendix 2 gives a number of examples regarding a possible constellation of hospital care spread over
several different hospital locations within one single hospital organisation.
New possibilities in the field of medical technology (minimal invasive therapy), developments in ICT
(telemedicine: monitoring and diagnostics at a distance using telecommunication technology) and further
development of (transmural) care chains for specific patient groups are expected to result in new forms.
2
In the follow-up feasibility study on distribution of hospital care, part one (Netherlands Board for Hospital Facilities
14 January 2002), as well as the Minister’s standpoint on this study (1 February 2002), these forms are explained in
further detail.
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3.5 Design of the general hospital building guidelines
The guidelines were drawn up on the basis of the different activities that take place in a hospital. In the
first place these are activities that concern the primary process, in other words the direct interaction
between the patient and the care provider (nursing, diagnostics and treatment). In addition there are
activities that have no direct relationship with the primary process, but are mainly focused on providing
support and services in a general sense.
Translated into spatial facilities, these different activities may be subdivided into three ‘blocks’:
A. patient-related facilities where the patients themselves are/may be present;

B. patient-related facilities where patients themselves are not present;
C. general & technical support services.
It should be added that this subdivision is not a blueprint for the way in which a hospital should be
divided up, but merely forms a plan based on the different activities within a hospital.
A. Patient-related facilities where the patients themselves are present
Three main function groups may be distinguished within this ‘block’ as follows:
• nursing;
• diagnostics & treatment;
• special functions (in so far as these are present).
The nursing main function group includes the spatial facilities for special care, general nursing,
paediatric nursing, maternity nursing (including delivery rooms), geriatrics and day nursing. However, in
view of the nature of the care provided, the day nursing could also be placed under the main function
group diagnostics & treatment, non-specific. From the assessment experience of the Netherlands Board
for Hospital Facilities, however, the day nursing unit appears in most cases to (still) form part of, or be
situated in the close vicinity of the facilities for nursing.
The diagnostics & treatment main function group includes the following spatial facilities: outpatient
appointment department, general organ function investigations, imaging diagnostics, nuclear medicine,
outpatient treatment, operation unit, emergency unit and physiotherapy.
The special function main function group includes the spatial facilities for dialysis, a rehabilitation day
treatment unit or a radiotherapy unit.
B. Patient-related facilities where patients themselves are not present
This ‘block’ includes the spatial facilities for central sterilising services, the pharmacy and the
laboratories (clinical chemistry, medical microbiology, clinical pathology).
C. General & technical support services
This ‘block’ includes general and staff facilities (such as central kitchen, linen service, restaurant and
technical service), as well as facilities for management and training.
There is a trend towards outsourcing some of the facilities listed under B and C to third parties. This is
particularly the case with the laboratories and pharmacy, administrative tasks, kitchen facilities, linen
service and technical service.
Based on examples from the consultancy experience of the Netherlands Board for Hospital Facilities,
the table below shows (as an indicative average) what the share in percentage terms of the different
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3
blocks is of the floor area on the basis of the usual function package of a general hospital. The
examples concern initiatives as currently being developed within the framework of the “new style”
hospital.
(main) function group Share as percentage

Standard package
Block A: patient-related facilities (patient present) 65%
Block B: patient-related facilities (patient not present) 10%
Block C: general & technical (non-patient-related) services 25%
Total 100%
3
Excluding special functions
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4 BASIC QUALITY REQUIREMENTS
4.1 Introduction
By analogy with the subdivision in the National Building Decree, the basic quality requirements are
described at different levels: the location, accommodation, conditions (including hygiene) and safety &
security.
In these guidelines, the basic quality requirements are described at the level of the location(s) and the
building structure situated there, and take the form of “open standards” in line with the provisions in
§ 2.1.
Where the conditions are concerned (mainly hygienic aspects and special climatic requirements), please
refer to the building guidelines for indoor environment and building-related installations of the
Netherlands Board for Hospital Facilities. For safety & security, please refer to the regulations of third
parties, such as the National Building Decree and the Working Conditions Act. Any additional or
deviating basic quality requirements at both of these levels are described in the specific building
guidelines.
In the specific building guidelines, further basic quality requirements are formulated for the relevant
hospital functions within accommodation (building structure). These are more in the nature of “closed
standards”, in line with the provisions in § 2.1.
The basic quality requirements formulated below at the level of the hospital as a whole and the basic
quality requirements as incorporated in the specific guidelines form the complete set of basic quality
requirements with which building plans for new hospitals have to comply.
4.2 Reachability
• A general hospital should be easily reachable by public transport, assessed on the basis of transport
frequency and the distance to the stop, and also by taxi, car or bicycle.
Generally speaking, this requirement is complied with if a general hospital is situated at one of the
geographic/demographic concentration points in its catchment area. A geographic/demographic
concentration point is a municipality where the population level and level of amenities (schools, retail
trade, recreation, public services) is such that a substantial proportion of the population in the catchment
area of the hospital is more or less automatically orientated towards that municipality.
4.3 Access
• The site needs to be easily accessible by patients, visitors and staff.
In this connection, specifications apply to pavements/ footpaths (minimum width, minimum free height,
maximum slope, maximum height of kerbs), ramps (minimum width, maximum slope and length, halfway
and end platforms), outside stairs (minimum width, maximum rise, installation, height and design of
handrails), material properties of paving surfaces (flat, rough and jointless) and lighting.
Regulations also apply to the measurements and layout of parking places.
There are additional requirements for the less able, such as the size of parking places and the height of
parking meters. Obstacles should be indicated by warning paving, continuous guiding lines must be
present.
• Taxis should be able to come right up to the main entrance and the entrance to the outpatient unit.
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• The entrance to the emergency department and if necessary the main entrance should be
accessible by ambulance.
• Public entrances to a hospital building should comply with minimum dimensions and also be
accessible by people with a physical handicap. These entrances should be covered over and
provided with good lighting.
• There are also specifications that apply to the entrance hall (sheltered situation, minimum
dimensions, location of the doors, lighting), thresholds (maximum heights) and door handles. In the
case of revolving or carrousel doors, there must be an extra swing or sliding door provided.
Where main traffic areas are concerned, specifications apply to e.g. minimum width, free access height,
the direction in which doors open, the presence and dimensions of rails along the walls and lighting.
The same applies to internal stairs, which have to comply with specifications concerning the maximum
rise and the minimum tread and for halfway landings.
Where lifts are concerned, specifications apply for example to cage dimensions and access height and
width (depending on the type of lift), the location of the operating elements and rails, and the manoeuvre
space in front of the lift door.
For further specifications, please refer to the Building Access Handbook and the Guide to the
Accessibility of Buildings in the Healthcare and Social Services Sectors.
4.4 Flexibility
The concept of flexibility refers to the degree to which a building is adaptable to changing space needs.
Flexibility is important in the healthcare sector because we are concerned here with a structural process
of change. As a result of this, spatial adaptation of buildings in this sector is inevitable. With a high level
of flexibility, these adaptations can be kept to a minimum, as a result of which the financial
consequences and the hindrance to management – both in terms of building nuisance and spatial and
organisational disintegration – remain within acceptable levels.
• The main structural design of a hospital should possess a high degree of flexibility. The building
structure should be simple to extend at different points and should be able to cope with internal
displacement.
A general hospital is a complex building with many rooms, the functional interpretation of which is highly
varied. A characteristic feature of today’s hospital architecture is that account was taken of future
changes and innovations in science, technology and policy when selecting the building structure.
Over the years, various architectural concepts have been developed in which flexibility is an important
basic criterium. In the past, the pavilion and Breitfuss models were among the most common used
structures for hospitals. From the time that flexibility aspects started to play a role, new structures
appeared such as the comb structure, cross structure, linear structure and variations on these
structures.
There are four types of flexibility, as follows: usage flexibility, disposal flexibility, layout or internal
4
flexibility and extension or external flexibility .
Usage flexibility
Usage flexibility concerns the possibility of changing the use made of a room/space without the need to
renovate that room/space.
Disposal flexibility
4
Nicolaï, R. and Dekker K.H.: Flexibility as a building strategy for changing healthcare. Utrecht 1991.
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Disposal flexibility concerns the possibility of removing building elements without a detrimental effect on
the cohesion of the building elements to be retained and with a minimum of hindrance.
Internal flexibility
The term internal flexibility refers to the possibility of interchanging hospital functions independent of the
supporting structure. A supporting structure with concrete columns makes this possible because the
internal fittings geared to the function can be removed without constructional consequences and be
reconstructed once again. The possibilities for internal displacement are positively influenced by
situating “hard” hospital functions (where specific conditions are laid down regarding equipment and
installations) next to “soft” hospital functions (with standard conditions with respect to equipment and
installations). The hard hospital functions can in this way displace the soft hospital functions, thereby
safeguarding future growth.
The “soft” hospital functions act in fact as buffers. One condition for these buffers is that the relevant
functions should not place high technical demands on the building and that their location is not of major
importance from an organisational point of view. Consequently, displacement of these functions should
not form any great problem.
External flexibility
The term external flexibility refers to the possibility of expanding the existing building structure.
Expansion possibilities are mainly programmed for functions where growth may be expected. In the
design, it is assumed that after the extensions have been carried out, the functionality of the whole
building will be guaranteed. For example: possible extensions will need to link up in a logical way to the
internal traffic system and to the main infrastructure of the installations.
When planning the hospital functions in relation to each other, it is also possible to obtain a flexibly
designed hospital. An example of this is a building structure where functions that do not form part of the
primary process are placed in separate building elements. The nursing, diagnostic and treatment
departments are concentrated in the main core of the hospital. The pharmacy, laboratories, storerooms
and the kitchen are located in service buildings at a distance from the main core.
4.5 Spatial relationships
The demands placed on spatial relationships between the different components of a hospital in the
architectural design are based on two elements. On the one hand requirements are formulated that are
derived from medical and logistic factors that are independent of the chosen organisational form of the
hospital. On the other hand, the spatial relationships are determined by the organisation of the hospital,
for which 3 possibilities have been outlined in chapter 3.
It may be necessary to lay down proximity requirements for different parts of a hospital on the basis of
medical or logistic arguments. These requirements are based on the different activities taking place in a
hospital and are separate from the requirements that can be formulated on the basis of the organisation
of the hospital. These activities are not dependent on the organisational form of the hospital.
Requirements based on medical arguments concern primary proximity requirements that are laid down
because fast transport is essential in the interests of the patient. A primary proximity requirement is
complied with if there is a direct link in a horizontal or vertical sense between two function groups or
departments of a hospital. Use can be made here of a lift with pre-selected control. A primary link of this
kind is essential between on the one hand the emergency unit and on the other hand the operating unit,
the imaging diagnostics unit and the location where emergency treatment is given to heart patients. A
primary link is also necessary between the operating unit and the intensive care and obstetric units.
Proximity requirements as a consequence of logistic factors are based on the volume of patient,
personnel or goods traffic between the different elements that form the hospital. The proximity
requirements arising from this aspect are subordinate to the primary proximity requirements based on
medical factors. It is worth recommending that the facilities to be used by outpatients should be situated
so as to be easily reachable in relation to each other. This particularly concerns the outpatient
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appointments desk, facilities for organ function investigations, the hospital laboratory and the imaging
diagnostics unit. Requirements can also be laid down in connection with the volume of goods transport.
As a rule, the operating unit and the central sterilising services unit are usually located so as to make
them easily reachable from each other.
On the basis of the type of organisation chosen by the institution (see also chapter 3), spatial
requirements can be formulated between the different components of the organisational units and
between these units themselves. The relationship requirements arising from the organisational form are
subordinate to the primary relationships formulated above. It is worth recommending, for the sake of
cohesion, that the chosen organisational form should be expressed in the spatial structure.
4.6 Quality of the environment
The quality of the built external and internal environment of hospitals not only has an impact on the well-
being of the care providers, but also on the healing process and behaviour of patients. This has been
shown by the many studies that have been carried out in this field in recent years.
The results of these studies have led to increased attention being paid to the psychological impact of
environmental aspects of healthcare institutions, including hospitals. In addition, attention is increasingly
being focused on the role of the patient in healthcare.
Studies have shown that the well-being of patients and visitors is promoted by an environment that:
• is easy to reach and where everything can be clearly found: for example a clearly recognisable
main entrance and good signposting inside the building;
• is comfortable and increases autonomy. The use of materials, colour and art play a role here;
• promotes the relationship with nursing staff: for example by the right location of the nursing station
on a ward and the presence of an adequate nurse call system;
• provides confidence and privacy, both visually (for example no undesirable views from the corridor)
and acoustically (for example by use of sound absorbent materials and locating mainly quiet
functions next to patient rooms);
• pays attention to relatives: for example facilities for visitors such as chairs in patient rooms,
possibilities for rooming in (children’s ward) and resting facilities should the presence of relatives be
necessary outside visiting hours;
• provides contact with the outside world: for example by making means of communication available
(radio, tv, telephone) and providing a clear view outside;
• is safe, secure and bright: for example by ensuring that sufficient daylight can penetrate, by using
non-institutional furnishings and lighting and avoiding long, obscure corridors.
The Netherlands Board for Hospital Facilities is planning to develop a tool based on the concept of the
English AEDET method that endeavours to objectify the assessment of the above-mentioned aspects. It
is the intention for the institutions themselves to be able to use this tool.
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5 ARCHITECTURAL CONCEPTS
5.1 Introduction
This chapter gives a few striking examples of hospitals that have either already been built or are in the
process of development. Examples are provided of each distinctive type of building. However, the fact
that these examples have been included here does not mean that a new hospital necessarily has to be
designed on the basis of one of these models. The examples show how concepts such as flexibility,
functional relationships and design were translated in the relevant period or are currently being
translated into the building structure of the hospital.
The following models will be dealt with:
− the Breitfuss model
− the double comb structure
− the arcade model
− the cross structure
− the branched structure
− the linear structure
− the pavilion structure
The building structure of a hospital has undergone a development that shows a decreasing dominance
of the ward block. The treatment and outpatient departments and the flexibility and design of the main
traffic areas have had an increasing impact on the main design of the hospital. Post-war hospital
building in the early decades generated many hospitals with imposing, sometimes monumentally
designed ward blocks. In the eighties, when flexibility became an important concept, more neutrally
designed hospital structures evolved. Subsequent developments show a more internally-oriented design
of the buildings, through the use of covered streets and plazas. Recently developed hospital designs are
characterised on the one hand by more emphasis placed on the design. On the other hand, since
hospitals have been increasingly built in an urban context due to land problems, fitting them into the
urban environment has become an important concept.
0270-02.Nt.doc 15
5.2 Breitfuss model
general
A typical feature of the Breitfuss model is that a tall building block with nursing functions is placed above
a flat building block with treatment and outpatient functions. The structure of the building shows a clear
division between the static nursing units in the ward block and the dynamic departments on the lower
two (or three) storeys. The external appearance of the ward block is often of an imposing design due to
its definitive status.
access
In general it may be said that the Breitfuss model produces a compact building with relatively short
walking distances. However, staff and visitors do have to make frequent use of the lifts. The number of
lifts is partly determined by the number of storeys of the ward block. In the case of highrise with around
10 floors, a considerable part of the ward block will be taken up by provisions for vertical traffic (lifts and
(emergency) staircases).
Due to its compact design, this model usually has a clearly recognisable main entrance.
functional relationships
Since the lowrise structure contains all diagnostic and treatment functions, it is possible to create good
spatial relationships with this type of building. Where the medical staff is concerned, the stacking of the
wards can mean that there is a considerable distance between the outpatient unit and the wards.
The Breitfuss model, originally designed according to functional planning of the care provided (outpatient
appointment unit, nursing unit, imaging diagnostics, laboratories, etc.), offers in principle sufficient
possibilities for planning the facilities for care provided on the basis of patient flows or on the basis of the
care process (see § 3.3). The Breitfuss model is less suitable for planning on the basis of target-groups.
flexibility
Where flexibility is concerned, account has only been taken of the possibility of adaptation and
expansion in relation to functions on the lowest floors. No possibilities for expansion or adaptation have
usually been provided for in the ward block. As a result of these limitations in the design, it is more
difficult with this type of building to comply with policy concerning the new style hospital that advocates a
shift from inpatient to outpatient.
0270-02.Nt.doc 16
example of Breitfuss model

Location and name of institution The Hague – Leyenburg Hospital
date of completion 1971
number of beds 750 beds
gross floor area 90,000 m²
5.3 Double comb structure
general
The double comb structure is characterised by a traffic zone in the centre from which different building
wings protrude like the teeth of a comb. The building structure is designed like a uniform grid. It
comprises many end walls, the so-called “open ends”, which make it simple to add extensions.
access
Due to the many open ends, the external architecture gives the impression of being unfinished. In
contrast with the Breitfuss model, for example, an overall picture of the hospital is not visible. If located
in the heart of the traffic zone, the main entrance may be hidden between the teeth of the comb.
In the case of large hospitals, this structure can lead to a sprawling design.
0270-02.Nt.doc 17
Functions which have to comply with the same requirements are grouped in one wing. From the point of
view of size and technical requirements, the teeth of the comb are geared to the functions to be housed
there. Practical experience has shown that stacking spatially related functions with specific requirements
regarding installations can also be successfully done in one wing. For example, the emergency
department is located on the ground floor, intensive care on the first floor and the operating unit on the
second floor. Other designs may include all laboratories in one wing, plus the pharmacy and the central
sterile supply services unit, or wings with only nursing functions.
The double comb structure is in principle suitable for all three planning models described in § 3.3 with
regard to accommodating the care organisation.
flexibility
The double comb structure was developed at a period when flexibility had become one of the most
important design criteria. Flexibility is guaranteed by extending the teeth of the comb or by extending the
traffic structure by adding a new wing. The basis structure of the hospital remains unchanged after these
extensions.
example of double comb structure

location and name of institution Nieuwegein – St. Antonius Hospital
0270-02.Nt.doc 18
5.4 Arcade structure
general
The arcade hospital emerged as a new model in the early eighties and has been used a number of
times in the Netherlands. In this model, the building elements of the hospital are linked with each other
by a glass-covered arcade for main traffic. Located on both sides of this arcade, on several floors, are
the rooms or internal access routes that look out onto the arcade. In the arcade on the ground floor are a
number of public amenities such as shops and a restaurant.
access
The high arcade is a clear structuring element. The main entrance at one end of the arcade is easily
recognisable. From the arcade, the vertical means of access to the upper floors are clearly visible.
It is evident from the hospitals built in accordance with this model that organisation can take place in
various different ways.
In Waterland Regional Hospital in Purmerend, the functions are located above each other. On the
ground floor are the outpatient clinics, on the first floor the operating department and the laboratories,
and above those a technical floor. The top two storeys house the nursing wards.
In Almere, Flevo Hospital is also based on an arcade model, but in this instance the functions have been
placed behind each other in different parts of the building. The outpatient departments, imaging
diagnostics and the accommodation for management functions are situated near the main entrance. In
the centrally located areas of the building are the operating department, the emergency department,
laboratories and physiotherapy. At the end of the arcade are two building elements containing the
nursing wards.
Maasland Hospital in Sittard, currently at the design stage, will also be built according to the arcade
structure. A section of the building for treatment functions is planned in the heart of the complex, at right
angles to the arcade. Parallel to the arcade on the ground floor and the first floor will come the outpatient
department facilities. Above these, on the top three floors, will be the nursing wards.
The arcade structure is in principle suitable for all three planning models described in § 3.3 with regard
to accommodating the care organisation.
flexibility
In a similar way to the double comb structure, the traffic structure (arcade) can be extended while
retaining the basic structure and new building elements can be added to it. The building elements linked
0270-02.Nt.doc 19
to the arcade usually have open ends on the other side that make it simple to add extensions in the
future.
example of arcade structure

location and name of institution Almere – Flevo Hospital
5.5 Cross structure
general
In the case of this model, two building blocks each in the form of a cross have been linked to each other
so as to create a large covered hall between the two building blocks. The covered hall is the centre of
the building and contains the central facilities.
0270-02.Nt.doc 20
access
The main entrance is located in on corner of the covered hall. This plaza is the heart of the structure and
contains the central facilities. The vertical access points in the cross-shaped building blocks are clearly
visible from the plaza. This structure lends itself well to the development of a relatively large hospital
within a compact design.
The best-known hospital based on this model is the Rijnstate Hospital in Arnhem. Virtually all the
nursing wards are housed on the top four storeys of this hospital. The outpatient departments and
treatment & diagnostics units are located on the lower level. Between the upper and lower level is a
technical floor. From the two intersections, a walkway diagonally crosses the central hall at a first floor
level, thereby reducing walking distances. The cross structure is in principle suitable for all three
planning models described in § 3.3 with regard to accommodating the care organisation.
flexibility
The open ends of the cross-shaped building sections can be extended while retaining the basic
structure.
example of cross structure

location and name of institution Arnhem – Rijnstate Hospital
0270-02.Nt.doc 21
5.6 Branched structure
general
Under the heading branched structure, a look will be taken at two completed hospitals where the most
characteristic element of the structure is formed by the number of branches and open ends. This
concerns the Canisius Wilhelmina Hospital in Nijmegen completed in 1992 and the Antonius Hospital in
Sneek completed in 1994. In both of these hospitals, a square central hall forms the heart of the
building.
access
The main entrance is directly linked to the central hall. The central hall is the centre of the structure and
contains amenities such as boutiques and a restaurant. From this central hall the patients and visitors
can gain access to the most important departments of the hospital. The main stairwells and the lifts are
easily accessible from the central hall.
The Canisius-Wilhelmina Hospital in Nijmegen was built according to this design.
With an average of 3 storeys, this hospital is relatively lowrise. The outpatient departments have their
own entrance, but this is located on the same side of the square as the main entrance. Most nursing
wards are located in the branches leading off the square. The operating department and intensive care
are situated on the top floor. The situation and size of the site made it possible to build a relatively
lowrise hospital. This means that all the wards have a pleasant view over the green surroundings.
The Antonius Hospital built in Sneek is also characterised by lowrise building. In this hospital, separate
buildings elements were developed per main function. The services building is located separately so
that this function can respond to future developments. Functions which require a higher building height
have been located on the top floor. This concerns the X-ray and operating departments, physiotherapy,
pharmacy and laboratories.
A branched structure is in principle suitable for all three planning models described in § 3.3 with regard
to accommodating the care organisation.
flexibility
Due to the existence of many open ends, a branched structure possesses by definition sufficient
external flexibility. The following observations may be made regarding flexibility in the Antonius Hospital.
The different function groups have been housed in separate building elements with a construction and
raster size geared to the function group. Supporting outside walls have been used for patient
accommodation, while diagnostic, treatment and service functions have a skeleton structure. Since each
0270-02.Nt.doc 22
main function is located at an open end, the possibility of expansion is guaranteed. All beds in the multi-
bed rooms are of equal quality due to the fact that the beds are located by a window. In addition, all
multi-bed rooms can be partitioned into maximum one-bed rooms.
example of branched structure
location and name of institution Sneek – Antonius Hospital

0270-02.Nt.doc 23
example of branched structure

location and name of institution Nijmegen – Canisius-Wilhelmina Hospital
5.7 Linear structure
general
For the draft plan for Vlietland Hospital in Schiedam, a design has been developed consisting of a single
linear block that can accommodate all hospital functions in accordance with their inter-relationships. The
depth of the block is approximately 22 metres and is designed for the application of a double corridor.
Stairwells and cable and piping shafts have been incorporated in a rational design in the central zone.
0270-02.Nt.doc 24
access
The linear block forming the hospital is designed with a number of kinks so that the overall shape
resembles a hairpin. An entrance is located on both sides and opens into a high glass hall that is
wedged between the linear building block. The different lifts and stairwells can be reached from the
central hall. In places where a short link is required for functional purposes, additional glass connection
corridors have been designed between departments located opposite each other. In this way acceptable
walking distances have been achieved.
function relationships
The dimensions of the linear building have been geared to house both outpatient clinics and nursing
wards. On different floors, outpatient departments are located next to nursing wards. In the case of
future bed reductions, wards can easily be converted into outpatient clinic space. This design is fully in
accordance with policy on new style hospitals where a shift from inpatient to outpatient is advocated.
flexibility
There are limitations regarding the external flexibility of the design of Vlietland Hospital on account of the
fact that it only has two open ends and due to the size of the site. Internal flexibility is good, due for
instance to the rational uniform design which makes it possible to interchange functions.
The linear structure is in principle suitable for all three planning models described in § 3.3 with regard to
accommodating the care organisation.
0270-02.Nt.doc 25
example of linear structure

location and name of institution Schiedam – Vlietland Hospital
date of completion 2006 (planned)
5.8 Pavilion structure
general
During the pre-war years, larger hospitals were built according to the pavilion structure. A cluster of
categorial hospitals was built on the site. This method was abandoned after the war. Today, however,
some designs for large hospitals are returning to the pavilion structure and opting for a plan according to
clinical entities, themes or type of care. An example of this is the design for the Isala Clinics in Zwolle. A
characteristic feature of the pavilion structure is that the spatial facilities that form part of the chosen plan
are grouped together.
0270-02.Nt.doc 26
access
The design of the new building for the Isala Clinics comprises four blocks, varying from four to six
storeys. Each block has an atrium. The building blocks will be built on three sides of the existing
complex. Situated beneath the new building blocks is a parking garage from which all four blocks can be
reached. In addition, the main entrance is located between two blocks, passing into a central hall into
which opens an extensive system of corridors providing access to all the building elements. This design
has several different entrances as a result of which extra measures will be necessary from the point of
view of security and surveillance.
The new building will house virtually all patient-related functions, organised per block according to
clinical entity. As you move higher up the building, facilities for outpatients decrease as inpatient facilities
increase.
The pavilion structure is particularly suitable for a plan based on care according to target-groups/clinical
entities.
flexibility
A design based on planning according to clinical entity in one or more building elements has a negative
effect on flexibility. Changes in activities and space between the functional units as a result of
developments in the care sector will be difficult to achieve in the future without a change in the basic
organisation principles.
External flexibility does exist, however, since in this design a number of building elements can be
extended at the ends. Account has also been taken of constructing an extra floor on top of the different
building elements.
0270-02.Nt.doc 27
example of pavilion structure

location and name of institution Zwolle – Isala Clinics
date of completion last section 2011 (planned)
0270-02.Nt.doc 28
6 FINANCIAL ASPECTS
6.1 Investment costs framework for new buildings
This chapter shows how the maximum investment costs can be determined on the basis of the currently
applicable Annual Note on Building Costs. The investment costs comprise three components: the direct
and building-related costs, the cost of the land and the starting costs.
Inventory costs for a general hospital are not assessed within the framework of the Hospital Provision
Act (WZV).
The investment costs framework for a hospital is determined by two quantities: the normative floor area
and the building costs per m².
Indicators have been included in the Building Standards Regulations for both quantities. Until now the
applicable floor area standard figure for hospitals, on the basis of which the normative floor area is
calculated, has been linked to the bed parameter. This parameter, which is exclusively based on the
inpatient flow, takes insufficient account however of the reduced use of beds in hospitals as a result of a
shift from inpatient care to outpatient care and day nursing.
On 26 November 2001, the Netherlands Board for Hospital Facilities advised the Minister in an alert
report to drop the bed parameter and change to an ‘adherent inhabitant’ parameter, and in addition to
the inpatient flow also allow the outpatient flow to be a determining factor for calculation of the normative
floor area of a hospital.
In the new calculation method, a market share will be determined per patient flow (inpatient and
outpatient adherency) that will be projected on the future population in 2010, leading to the future
adherency per patient flow of the hospital. In addition, this future adherency per patient flow will be
multiplied by a normative floor area per patient flow (inpatient: 162 m² per 1,000 adherent inhabitants,
outpatient: 104 m² per 1,000 adherent inhabitants).
The normative floor areas per patient flow calculated according to the method together form the total
normative permissible floor area for the normal function package of a general hospital.
In some cases, the general hospital also has special functions for which the space requirements can be
determined with the help of supplementary floor area indicators adopted by the Netherlands Board for
Hospital Facilities on 7 October 1996 (recommendation concerning capacity parameters article 18
Hospital Provision Act) and on 18 November 1996 (recommendation concerning other PM items relating
to space requirements standardisation).
The investment costs framework for a new building intended to completely replace a hospital will
subsequently be determined by multiplying the total gross floor area (normal + specific functions) by the
building price per m² for a hospital as incorporated in the Annual Note on Building Costs of the
5
Netherlands Board for Hospital Facilities .
5
As long as the Minister has not yet agreed to the new calculation method given in the Alert Report “Method of
calculating normative floor area; alternative to the bed parameter” (Nov. 2001), the floor area calculation based on
the bed parameter continues to apply (see also the aforementioned alert report ).
0270-02.Nt.doc 29
By way of illustration, an investment costs framework is determined in the table below on the basis of a
fictitious example.
Gross floor area

Inpatient Outpatient Total
162 m²/1,000 104 m²/1,000
inhabitants inhabitants
Standard package
Inpatient adherency 150,000 inhab. 24,300 m²
Outpatient adherency 160,000 inhab. 16,640 m²
Total 40,940 m²
PM items 3,000 m²
Total floor area 43,940 m²
Building price per m² *) € 2,212.-
Total investment costs framework € 97.2 mln
*) Source: Annual Note on Building Costs 2002, incl. VAT, price level 1 Jan. 2001, exclusive land, inventory and
starting costs
Please refer to the provisions in the Annual Note on Building Costs for land, inventory and starting costs.
6.2 Practical application
Given the investment costs framework, a hospital organisation has the freedom to develop the required
architectural care infrastructure as it sees fit. Occasionally, for example in a multi-location model or in
order to facilitate transmural cooperation with other care facilities (eg general practitioner centre,
convalescent unit), a hospital organisation can create more floor area within the framework for
investment costs than is permitted within the calculation method norms.
Conversely, a hospital organisation can opt to create less floor area than would be permitted according
to the calculation method norms and to use the investment costs that hereby become free to finance
additional investments in ICT for example. It should be added here that if the reduction in the floor area
is a result of outsourcing specific services (see § 3.5), the framework for investment costs will be
reduced accordingly, in line with the CTG (National Health Tariffs Authority) policy regulation on capital
costs when outsourcing.
The mechanism described above is applicable one to one in cases of new building development that is
intended to completely replace a hospital organisation.
In situations where this is not the case, such as large-scale concentrated building adjoining an existing
hospital location that has to be renovated, determination of the investment costs framework takes place
as follows. In the first instance, the standard permissible floor area of a hospital organisation is
calculated on the basis of the method described in § 6.1. You then take a look at the size of the internal
layout losses of the existing hospital location, on the basis of which it can be determined how many m²
of new building or renovation will be provided for. The size of the new building is multiplied by the
building cost per m² for a hospital as stated in the Annual Note on Building Costs, while the investment
costs for the renovation depend on the physical-functional and technical installation state of the building
at the existing hospital location as well as the projected functions.
0270-02.Nt.doc 30
The building cost per m² stated in the Annual Note on Building Costs concerns an average price per m²
that includes both expensive m² (for example for the operating department, laboratories) as well as
cheap m² (for example for office-type facilities). In the specific standards with basic quality requirements
there are differentiated cost norms for the relevant functions. These differentiated cost norms can be
used as a basic criterium in situations where a hospital organisation is only intending to put up a new
building for a specific hospital function.
0270-02.Nt.doc 31

General Hospital Building Guidelines - Netherlands

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THE GENERAL HOSPITAL

BUILDING GUIDELINES FOR NEW BUILDINGS

Adopted by the Netherlands Board for Hospital Facilities on 7 October 2002

2. GENERAL PRINCIPLES AND PRECONDITIONS 2

3. BASIC PRINCIPLES IN RELATION TO CARE 4

4. BASIC QUALITY REQUIREMENTS 11

2 GENERAL PRINCIPLES AND PRECONDITIONS

Basic quality requirements

2.3 Supplementary areas

3. BASIC PRINCIPLES IN RELATION TO CARE

3.2 Specialist medical care

3.3 Organisation of healthcare

Planning on the basis of target-groups/clinical entities

Theme 1: Brain & sensory organs

Source: Erasmus MC Rotterdam

Planning on the basis of patient flows

Source: Deventer Hospitals

Planning on the basis of the care process

Source: Orbis Sittard

3.4 Differentiated care

3.5 Design of the general hospital building guidelines

A. patient-related facilities where the patients themselves are/may be present;

A. Patient-related facilities where the patients themselves are present

B. Patient-related facilities where patients themselves are not present

C. General & technical support services

(main) function group Share as percentage

4 BASIC QUALITY REQUIREMENTS

• The site needs to be easily accessible by patients, visitors and staff.

4.5 Spatial relationships

4.6 Quality of the environment

5.2 Breitfuss model

example of Breitfuss model

5.3 Double comb structure

example of double comb structure

5.4 Arcade structure

example of arcade structure

5.5 Cross structure

example of cross structure

5.6 Branched structure

example of branched structure

location and name of institution Sneek – Antonius Hospital

example of branched structure

5.7 Linear structure

example of linear structure

5.8 Pavilion structure

example of pavilion structure

6.1 Investment costs framework for new buildings

Gross floor area

6.2 Practical application

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