THE GENERAL HOSPITAL BUILDING GUIDELINES FOR NEW BUILDINGS

(reportnumber 0.107)

Adopted Approved

by the Netherlands Board for Hospital Facilities on 7 October 2002 by the Minister for Health, Welfare and Sports on 19 November 2002

General hospital building guidelines

CONTENTS 1. 2. 2.1 2.2 2.3 3. 3.1 3.2 3.3 3.4 3.5 4. 4.1 4.2 4.3 4.4 4.5 4.6 5. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6. 6.1 6.2 INTRODUCTION GENERAL PRINCIPLES AND PRECONDITIONS Principles Preconditions Supplementary areas BASIC PRINCIPLES IN RELATION TO CARE Upscaling Specialist medical care Organisation of care Differentiated care Design of the general hospital building guidelines BASIC QUALITY REQUIREMENTS Introduction Reachability Access Flexibility Spatial relationships Quality of the environment ARCHITECTURAL CONCEPTS Introduction Breitfuss model Double comb structure Arcade structure Cross structure Branched structure Linear structure Pavilion structure FINANCIAL ASPECTS Building development investment costs framework Practical application 1 2 2 2 2 4 4 4 4 8 9 11 11 11 11 12 13 14 15 15 16 17 19 20 22 24 26 29 29 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 Boards 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 superspecialisation 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. Subspecialisation, 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 patients 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

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 patients 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 hospitals 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 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 targetgroups 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 Ministers 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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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) Block B: patient-related facilities (patient not present) Block C: general & technical (non-patient-related) services Total

65% 10% 25% 100%

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 todays 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

Nicola, 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 wellbeing 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 (childrens 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.

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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.

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example of Breitfuss model Location and name of institution date of completion number of beds gross floor area

The Hague Leyenburg Hospital 1971 750 beds 90,000 m

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.

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functional relationships 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 date of completion number of beds gross floor area

Nieuwegein St. Antonius Hospital 1979 579 beds 61,000 m

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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. functional relationships 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

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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 date of completion number of beds gross floor area

Almere Flevo Hospital 1991 213 beds 19,000 m

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.

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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. functional relationships 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 date of completion number of beds gross floor area

Arnhem Rijnstate Hospital 1994 750 beds 82,000 m

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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. functional relationships 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

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main function is located at an open end, the possibility of expansion is guaranteed. All beds in the multibed 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 date of completion number of beds gross floor area Sneek Antonius Hospital 1992 270 beds 29,000 m

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example of branched structure location and name of institution date of completion number of beds gross floor area

Nijmegen Canisius-Wilhelmina Hospital 1992 638 beds 63,000 m

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.

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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.

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example of linear structure location and name of institution date of completion number of beds gross floor area

Schiedam Vlietland Hospital 2006 (planned) 453 beds 48,000 m

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.

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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. functional relationships 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.

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example of pavilion structure location and name of institution date of completion number of beds gross floor area

Zwolle Isala Clinics last section 2011 (planned) 911 beds 126,000 m

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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 m. 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 m per 1,000 adherent inhabitants, outpatient: 104 m 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 m for a hospital as incorporated in the Annual Note on Building Costs of the 5 Netherlands Board for Hospital Facilities .

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 ).

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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 162 m/1,000 inhabitants Standard package Inpatient adherency 150,000 inhab. Outpatient adherency 160,000 inhab. Total PM items Total floor area Building price per m *) Total investment costs framework 24,300 m 16,640 m 40,940 m 3,000 m 43,940 m 2,212. 97.2 mln Outpatient 104 m/1,000 inhabitants Total

*) 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 m of new building or renovation will be provided for. The size of the new building is multiplied by the building cost per m 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.

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The building cost per m stated in the Annual Note on Building Costs concerns an average price per m that includes both expensive m (for example for the operating department, laboratories) as well as cheap m (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.

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