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Hospital Design: Evolution of Crododiles Rather Than the Dodo Marianus de Jager Sharp Shop Architects, South Africa. ABSTRACT There is an inherent paradox in hospital architectural design in as much as a hospital is a purpose-built structure where form is determined by medical function and not necessarily its ability for flexibility and adaptation. If the building is too purpose-built this will affect future adaptation and result in a “Dodo” that will become extinct. The lifecycle will be shorter than a building which is purpose-built with enough flexibility to adapt and morph into a “crocodile”, which is to say a tried and tested design that is stable and adapted over time to its environment relevant to its continued survival. This paper examines some of the design factors which embed or hinder adaptability in hospital design. Drawing on a portfolio of hospital projects in SA, the author discusses and compares current approaches to healthcare infrastructure. The structure of healthcare delivery is about to undergo a major overhaul with the introduction of a National Healthcare Insurance scheme. At this point, the author argues, it is appropriate to examine the implications of healthcare design strategies, design solely for present medical function or design for flexibility and adaptability. The question thus posed is: what approach to building design will ensure that future hospitals in South Africa are robust enough to withstand the test of time. KEYWORDS: Hospitals, design, flexibility, adaptable, South African. DEFINITION Since the rebirth of South Africa as a democratically free state in 1994, there has been the deepening distinctiveness of two healthcare service provision models. The first type – the public sector – exists in the custody of the various nine autonomous provincial departments of health and local government authorities. This is the platform to provide services for 65% of the population and does so with 40% of health care funding. The second type – in the private domain and with a relative investment of 46% of the expenditure provides services for the privately medically insured population which accounts for 35% of the population (McIntire et al:19). This imbalance in expenditure and benefit has prompted the re-engineering of the healthcare finance model and healthcare delivery systems. This effort will be heralded by the imminently planned introduction of a gradually phased National Health Insurance scheme which seeks to provide accessible and fair healthcare for all South Africans through a compulsory ring-fenced progressive tax base. Each of these two healthcare service models has given rise to distinctive hospital architecture.

In both types there is an inherent paradox in design in as much as a hospital is a purpose-built structure where form is determined by medical function and not necessarily its ability for flexibility and adaptation. If the building is too purpose-built this will affect future adaptation and result in a “dodo” that will become extinct. The lifecycle will be shorter than a building which is purpose-built with enough flexibility to adapt and morph into a “crocodile”, which is to say a tried and tested design that is stable and adapted over time to its environment relevant to its continued survival. At this point, with the imminent introduction of a National Healthcare Insurance scheme, it is appropriate to examine the implications of healthcare design strategies and to speculate whether either type sufficiently balances the medical functional imperatives with design for flexibility and adaptability to survive or whether lessons drawn from both sectors may inform a new hybrid open building system. The question thus posed is: what approach to building design will ensure that future hospitals in South Africa are robust enough to withstand the test of time? The dodo (Raphus cucullatus) was a flightless bird endemic to the Indian Ocean island of Mauritius. Related to pigeons and doves, it stood about a meter tall, weighed about 20 kilograms, lived on fruit, and nested on the ground. The dodo has been extinct since the mid-to-late 17th century. It is commonly used as the archetype of an extinct species because its extinction occurred during recorded human history and was directly attributable to human activity.

The dodo had a flawed design in that over time meant it didn't adapt to the threat in its environment and thence disappeared due to its inability to avoid its’ predators i.e. humans

Figure 1. The dodo. (Source: Wikipedia)

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A crocodile is any species belonging to the family Crocodylidae. Member species of the family Crocodylidae are large aquatic reptiles that live throughout the tropics in Africa, Asia, the Americas and Australia. Crocodiles tend to congregate in freshwater habitats like rivers, lakes, wetlands and sometimes in brackish water. They feed mostly on vertebrates like fish, reptiles, and mammals, sometimes on invertebrates like molluscs and crustaceans, depending on species. They are an ancient lineage, and are believed to have changed little since the time of the dinosaurs. They are believed to be 200 million years old whereas dinosaurs became extinct 65 million years ago; crocodiles survived great extinction events.

The crocodile has a tried and tested design that is quite stable and adapted over time to conditions in its environment relevant to its continued survival .

Figure 2. The crocodile. (Source: Wikipedia) A building is the spirit of the age; theory and functional imperative frozen at a point in time. Out-of-date versus extinction is a product of design and adaptability over time.

In the experience of the author, some key factors that can demonstrably impact the adaptability of the organism (healthcare buildings) and that may result in extinction or adaptation over time include: contract period, changing disease profiles, information technology, equipment (beds, diagnostics), electrical supply and usage in healthcare environment, staffing skills and shortages, global trends versus local solutions, architectural style and building evolution over time. Each of these factors is examined in terms of how they apply to some current typical examples of each of the two identified hospital types in order to speculate which response may survive the “great extinction event” posed as the structure of healthcare delivery in South Africa undergoes its’ major overhaul. CONTRACT PERIOD – PROJECT TIMEFRAME No matter how fast we construct buildings, the time it takes between planning and use means that the building is dated at the time it is handed over. This timeframe varies according to the nature and circumstances of the contract and construction. In the

South African private healthcare context it currently averages 24 months. In public healthcare the time period varies between 36 and 60 months and frequently stalls indefinitely. Perception of the relevance of any particular building is partly determined by temporal proximity of idea and realisation. Fast-track contracts realise more quickly and in a real sense the parties involved may be inclined to feel that the building at completion is relevant to the ideas visualised at the planning stages. Conversely, post-project feedback studies show that protracted building contract times tend to leave healthcare architecture clients and consultants feeling that the trends in the medical field have supplanted their building and that they will need to change or update the facility to stay current with the trends in their field.

Private healthcare tends to a fast-track contract structure whereas public healthcare tends to protracted conception periods because of the checks and balances built into the process. In the private sector executive management makes investment decisions and tends to streamline this by consultation with preferred specialist professional teams and standardised design approaches. Private hospital groups maintain competitive advantage through capitalising on past experience and excellent intra-group communication to avoid repeating mistakes which improves efficiency and effectiveness of healthcare architecture. The public sector decision-making process has vacillated between local or provincial authority as the case may be and facility management. The first strategy is the enemy of equity (given the lack of norms and standards, regulations and guidance); the second the enemy of efficiency or sensitivity as it is removed from point of service. The extended contract periods which result lead to fatigue and also tends to entail breaks in continuity and institutional memory loss experienced in extended timeframes due to churn and high staff turnover. This fragmented experience of the building process – which is disproportionately more prevalent in the public sector – undermines user-client satisfaction. If user-client satisfaction is a goal (and given critical staff shortages this may be crucial to successful health service delivery) then, as South Africa prepares for National Health Insurance, it should consider streamlining contractual processes in order to improve stakeholder satisfaction. CHANGING DISEASE PROFILES Over time disease profiles change. In the 1500’s the leading cause of death was infection, poor hygiene, poor diet and poverty. In the 1700’s the leading cause of death was consumption (TB), ague and smallpox. In the 1900 the leading cause of death was the flu, TB and diarrhoea. In the 1960’s the leading cause of death was heart disease, cancer and degenerative diseases. In the 2000’s the leading cause of death is lower respiratory infections, heart disease, diarrhoea, HIV. Currently we have seen viral infection from

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various strains of influenza and closer to home the pandemic emergence of multi and extensively drug resistant TB.

Figure 3 and 4. Disease profiles in different income groups. (WHO website) Disease profiles are determined by region, the social norms and affluence of a society. Each of these diseases requires its own treatment regime and specific design factors that allow for effective treatment without infecting or endangering the staff that are treating the patients. Florence Nightingale was an accomplished statistician. Through careful recording of infection rates introduced the evidence-base to support cleanliness in hospitals and bed spacing to reduce cross infection. This has persisted as the basis for the modern hospital design.

Recently infection prevention and control has been recognised as one of six national priorities. Airborne infection measures to appropriately address the current specific risks of the South African epidemiological landscape can profoundly affect building architectural design and engineering. Infection prevention solutions vary from private to public sector according to their differing resource allocations and disease profiles. The threat of airborne infection is more profoundly experienced in the public sector because of the strong socioeconomic bias of TB and higher demand (characterised by overcrowding). This is also dealt with in the context of a resource constrained sector. Consequently in more basic levels of service public sector tends to favour technologically simpler natural ventilation solutions which require less preventative maintenance and hence consume less operational budget. By contrast the private sector has not felt the

full brunt of the TB epidemic – a luxury which may not continue in the re-engineered service – and has frequently made use of mechanical ventilation systems which are designed mainly for indoor environmental control and patient comfort rather than for airborne pathogen mitigation

Figure 5. Ventilation criteria in TB wards. (Source CSIR) Large openings that allow unobstructed air flow that diffuse pathogen droplet nuclei per volume, and larger allocated building volumes per capita reduce risk of airborne infection. Studies have demonstrated that some old hospitals with large windows and high ceilings could be better than the newer more efficient deep space planned and mechanically ventilated facilities (Escombe et al: 10).

But does this mean that the latter are doomed to extinction or can they prevail through adaption? As isolation rooms or wards for treating infectious diseases generally influence design, so too other specific diseases influence healthcare facility design. Thus the building’s design and layout adapts to the people and their diseases at that point in time. At any given time, hospitals need to be responsive to their local communities. When community members are young, there is a need for paediatrics and maternity services. Over time, as the community ages, and if it is relatively stable (which is a prevalent pattern in South Africa as a growing, developing nation with emergent middle class) then the medical profile changes and the hospital needs to accommodate a different set of patient needs. In societies that have an aging population profile, the design input with regards medical care will be integrated into the residential unit at varying levels and has become a sub speciality all of its own with affluent people living longer. In South Africa life expectancy across the board has dropped disproportionately affecting socioeconomically disadvantaged. This is pertinent to both public and private healthcare as well as both developed and developing societies, the reasons and cost centres vary.

In South Africa there is talk of a triple burden of disease. The first is primary healthcare diseases, which are high mother and child mortality, TB and malaria. The second is chronic lifestyle diseases, heart conditions, diabetes and or strokes and other stress related illnesses. The third is the high trauma

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from motor vehicle accidents and crime. South Africa shows primary healthcare diseases the same as developing counties in conjunction with lifestyle diseases more associated with developed countries. High trauma levels characteristic of South Africa is an anomaly for both. Usually developing countries don't sustain motor vehicle accidents and crime because of a shortage of resources (other than conflict areas) and developed counties don't have this either due to a developed policing system and law enforcement. This means that designers are exposed to varying degrees of healthcare planning, competing needs, and a need to identify which is the most appropriate for an area and how it is likely to change over time.

Often the difference between obsolescence and flexibility is experience or a vision by the designers that prevent buildings being locked into singular function facilities that are unable to change and become inefficient in new roles. INFORMATION TECHNOLOGY Information technology has rapidly transformed hospital functionality and rapidly transforms itself. Information technology allows an interconnectedness that wasn't part of facilities previously, now designers have server rooms and control centres where a host of electronic data interfaces with the patients, staff and building management systems. This connectivity adds a layer of servicing, specialised spaces and support infrastructure. These systems make a paperless hospital technologically possible and potentially reduce patient file storage area but increasing other aspects like the electrical loading and backup systems to keep the electronic systems operational. The more ambitious of these systems envision a total integration into a singular operating and or management system, items like: security monitoring, access for staff, patient data and various levels of access, staff data and time management, reporting via diagnostics, x-ray and pathology, electronic load monitoring on electrical supply, building management systems that control the building environment, integrated stock control and remote ordering, statistical reporting on patient profiles and occupancies, pharmacy control via integrated networks that monitor patients. Private healthcare tends towards the high end information technology (with fully redundant electrical supply systems to address public electricity supply uncertainty). The public sector is incorporating hybrid systems as part of their transition. EQUIPMENT Along with information technology support equipment is changing as well. Beds are increasing in length and width to accommodate additional paraphernalia that make the bed more versatile for a variety of medical functions within a single facility, evolving electronic monitoring, and easier for staff to manage patient comfort. These impact the minimum spaces needed at the attending and non attending

sides of the bed, as well as openings, lifts and the various corridors sizing in a facility. In regulations which apply only to the private sector, the norms and standards (R158) specify minimum open space requirements around beds based on conservative ergonomic needs analysis

Using an oversimplified graphical analysis method it can be demonstrated that a relatively minor evolution of equipment size (in this case beds) coupled with a design principle (application of R158) can substantially alter cost and area requirements. Applying the R158 norms to a two bed ward layout with a 1995 standard bed yields a minimum room sizing of 15.02m². Applying the same R158 norm to 2011 bed yields a minimum room size of 16.15m². This is a 6% increase on the room size. As a rule of thumb, in a 210 bed hospital with a foot print area of 19 250m² (a recently completed projects) would require an additional 1155m² and an estimated additional R 23.1 million initial capital investment just because the bed has increased marginally in size.

Figure 6. Graphic analysis of norms applied to a two bed medical ward. (Source: author) MOOT Algemene Hospital – Pretoria was originally a dedicated stand alone paediatric hospital which was bought by a private hospital group. Their business plan was to convert portions of the facility into adult beds (the patient profile had changed) that had a better return on income. The challenge in the reconfiguration was that the wards where designed for children's hospital cots, which are substantially smaller than adult beds. The cots had the regulatory distances between each other but due to inconvenient positioning of concrete structural elements flexibility

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and adaptability of the facility to an efficient adult configuration were severely limited. Bed numbers had to be substantially reduced, generated pockets of inefficiencies all over and compromising the business model.

Subsequently our practice designs paediatric wards to accommodate standard hospital beds so that the ward can adapt in over time as the hospital’s demographics change. The additional area in the case of paediatric use is always used by concerned parents. In the South African private sector, investment decisions are frequently imposed on the consultant team by the investing party on the basis of minimising initial capital investment as capital is scarce and expensive and the market is highly cost-sensitive and competitive. Provision of additional space even if it can be used for concerned parents (and even if this may provide a competitive advantage) is uncommon practice in the private sector and needs to be strongly motivated by the professional design team.

Jane Carthey notes that there are orders of magnitude for rates of change which vary by element more or less as follows: site 50-500 years, structure 30 – 50 years, skin 20 – 30 years, services 10 – 20 years, space plan 5 – 20 years and stuff 0 – 1 year (Carthey: 41). Discrepancies between rates of change of different elements are a challenge for healthcare facility designers in conventional design, construction and asset management practice.

Consequently building infrastructure which typically endures 30-50 years but which is designed to accommodate super-specialised equipment may be out of sync with space adaptation needs in the medium and long term. Items in diagnostics like x-ray machines and the support equipment is (generally) getting smaller, with lower hazardous radiation levels and may be accommodated in smaller spaces with more electronics. Items that lasted 10 years now turn over in six years, this impact on the spaces and their re-use. Large expensive pieces of equipment are reducing in price which means that they tend to become obsolete sooner (term of financing) and are more likely to be replaced sooner. The increase in monitors for patients means that there needs to be more or larger equipment stores built into a ward to accommodate the equipment when not in use or when charging the rechargeable batteries.

This has also lead to the addition of clinical stores and workshops where this specialised electronic equipment is serviced or repaired on site. More and more the inclusion of these items is to reduce staff workloads but also requires specialised training rooms where the staff is updated on the equipment, their use and problem solving or reporting. The specialised equipment also needs extra electrical loading and often extra mechanical ventilation to cool the electronics. Private and public healthcare are focusing on these items for the same reasons and regardless of the sector these will be determining factors in the design evolution.

ELECTRICAL USAGE AND SHORT SUPPLY South Africa has a challenge in meeting current electricity demand, resulting in disruptions in supply and a sudden exponential increase in cost of electricity. These factors affect essential services like hospitals very acutely. On the one hand there is a shortage of supply as a resource issue and on the other hand we have an increase in demand brought about by the increasing adoption of increasingly sophisticated technologies. Often this increasing sophistication is driven by a need to use technology in response to staff shortages. A solution is the integrated building management systems that cut down on unnecessary electric usage and manages the power consumption via various management strategies. Heat pumps, solar heating and solar control are being systematically introduced to reduce loading in the private sector as a means of relieving burden of high electricity cost with the collateral benefit it being a more “green” and sustainable resource. Private and public healthcare are increasingly focusing on these items for the same reasons and regardless of the sector these will be relevant in the design evolution. SKILLED STAFF SHORTAGES Healthcare workers are in critically short supply in South Africa (McIntire: 5). Whilst this is a worldwide phenomenon, developed countries attract skills away from developing countries on an economic bias. Healthcare architecture that is not adapted to this constraint is doomed and there are several public facilities in existence which have been unable to operate. A strategy adopted predominantly in the public sector is to provide on-site staff accommodation to attract staff to facilities (mainly in rural areas) where services may be needed but where professional healthcare workers may not be available. Private sector has largely avoided these areas as they may present unfeasible business propositions due to suppressed socioeconomic demographics of these areas. In both sectors hospital designers are inclined to minimise travel distances for reduced staff complement and linking symbiotic functions through careful planning in order to maximise acuity. Enabling technologies such as electronic monitoring allows for less staff to deal with more patients but the reliance on electronic monitoring is financially feasible in private facilities and developed counties but not (yet) so in the public sector. The question may also be raised whether over-reliance on electronic patient monitoring – particularly when used in combination with single-bed ward configurations may alienate patients and undermine the healing environment.

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GLOBAL TRENDS VERSUS LOCAL SOLUTIONS In developed counties and in the private sector in South Africa the trend is towards a hotel like patient environment, with single occupancy bed rooms and more privacy. This leads to a higher staff requirement to service the one bed units or electronic monitoring; both are expensive options that are affordable only in private healthcare. In developing economies there is a predominance of two to six (or more) bed ward options. These require less staff to patient ratio and as a spin-off the patients become part of the nursing staff through their communal awareness. Locally we have a society that has a strong social basis so it could be argued that two to four bed ward configurations are more appropriate for South Africa. Concern for fellow patients means that patients are as likely to assist in the monitoring of patients as nursing staff; this reduces the load on staff and works within the social norms of South African society. Furthermore four to six bed ward configurations use less space per patient, reduce capital cost, reduce staff needs and improve circulation distances compared to their single and double bed counterparts. Global trends stack hospitals vertically because of the premium on land. Locally, in many contexts well-designed horizontally-spread hospitals with less reliance on mechanical circulation and servicing are a tried and tested typology. Only in dense urban environments are vertically stacked solutions prevalent. Architectural design solutions are sometimes copied from developed contexts without appropriate adaptation in order to create the impression of sophisticated healthcare delivery but this approach inevitably leads to extinction due to capacity and resource constraints leading to failure to afford and maintain these facilities. ARCHITECTURAL STYLE Private healthcare groups tend to minimise initial capital investment to minimise financial exposure and maximise profit. In order to sustain ongoing

operation this sector relies on maintenance-intensive (tax-deductable) management of building stock and a rapid renovation cycle. There was an anecdotal rule of thumb that a facelift would be performed on a facility approximately every seven years and a refit every 14 years – reinventing a facility within a style matrix responsively for a fluid and style-orientated market.

Public healthcare architecture faces different constraints. Capital finance is accessible through the National Treasury and though bureaucratic and slow there is little institutional incentive (or until recently frame of reference) to economise to the extent apparent in the private sector. However facility maintenance regimes in the public sector have been almost universally exceptionally poor. In certain cases, hospital architects have responded through specifying very robust materials and fittings for new public facilities. These may then rejected by building users because of their user-unfriendliness (Stainless steel toilets, Western Cape). Alternatively the private sector architectural styling is copied but performs poorly in the absence of maintenance and refurbishment culture. The public sector is characterised by inconsistency in architectural allegiance and ambivalence of style. BUILDING EVOLUTION The most basic evolution is simply that a facility will grow incrementally and expand beyond the borders and boundaries of the original envelope. Careful planning will not always cover these eventualities but flexible design strategies can accommodate future extensions.

In 1994, A3 Architects undertook major additions and alterations to the Sunward Park hospital, Boksburg. Over the ensuing 17 years an additional four major phases were added to the facility as it outgrew its original shell, added beds, increased services and introduced support infrastructure.

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Figure 6. Adaptation over time at Sunward Park Hospital. (Source: author) ADAPTABILITY, DISENTANGLEMENT AND LOCUS OF DECISIONS Most hospitals historically are purpose-built, highly specialised structures which have by and large escaped the generic typologies of speculative investment (such as that experienced in office building and residential markets). A new generation of hospitals, such as INO Hospital in Bern, Switzerland, exploit open building, flexible construction solutions that aim to allow endless permutations and flexibility over the life cycle of the building.

Right now may be an opportune moment in history to entrench open building design strategies with the introduction of the National Health Insurance. When better to rethink architecture than when new policy, legislation and guidance are formulated? Hospital building infrastructure which can fluidly respond to the various pressures discussed above, such as variations in epidemiology and demography; equipment and information technology; skills, energy and resource availability; and architectural style; as well as emerging and unanticipated pressures may well have the necessary characteristics to ensure its continued relevance. Disruptions to ongoing healthcare service provision could be reduced by choosing open building technologies over conventional construction techniques when undertaking additions and alterations. Elements could be renewed at different rates according to their particular life spans or functional requirements if they are disentangled, which could potentially advantage financial management, and extend the useful service life of hospitals. If investment decisions in overall hospital building envelope were made at local or provincial authority level but detailed resolution and ongoing evolution could be the ambit of the facility, it could go

some way to ensuring building relevance, stakeholder satisfaction (facility “own” the design process), improving equity (fair funding distribution located centrally), quicker contract period (less bureaucracy). However, several formidable barriers would need to be overcome in order to universalise this approach. Conventional professional design and specification practices, construction techniques and industry approach are likely to persist as the required widespread re-skilling or up-skilling would be expensive and time-consuming. Given this and the continuing need to provide healthcare infrastructure in the era of National Health Insurance, it looks like open building practices are more likely to succeed if introduced organically and incrementally as they gain traction over time rather than as a self-conscious imposed building philosophy. In this way open building strategies themselves may need to be crocodiles to avoid being dodos. REFERENCES Carthey, J. Health asset and facility management.

www.chaa.net.au (accessed 2011-03-11) Escombe, R.A., Moore, D.J.A., Gilman, R.H., Navincopa,

M., Ticona, E., Mitchell, B., Noakes, C,. Martinez, C., Sheen,P., Ramirez, R., Quino, W., Gonzalez, A., Friedland, J.S., Evans, C.A., 2009. Natural Ventilation for the Prevention of Airborne Contagion. PLoS Medicine 6:3, 0-11. www.plosmedicine.org .

McIntyre, D., Thiede, M.,Nkosi, M., Mutyambizi1, V., Castillo-Riquelme, M., Gilson, L., Erasmus, E., Goudge, J, 2007. A critical analysis of the South African Health System. web.uct.ac.za/depts/heu/SHIELD/reports/SouthAfrica1.pdf