The revolutionary concept of vertical integration that first allowed hospitals to stack the patient bed tower above the diagnostic and treatment base opened the door to a new paradigm of hospital organization.
Over the course of history, the developments in vertical transportation, beginning with Otis’s invention of the first “safe” elevator in 1853, may have brought about new possibilities for a more free organization of the ground floor plan, but the concurrent success of new procedures triggered the increasing complexity of the diagnostic and treatment (D&T) base.
While the ability to exploit the vertical dimension has the potential to reduce both travel distances and building footprints, as large urban hospitals moved away from sprawling courtyard plans like St. Thomas's Hospital in London (1871), the watershed moment in hospital planning was tempered by simultaneous advances in surgical procedures.
Early in the 20th century, the development of the X-ray and anesthesia had a great impact on the hospital form, as the increasingly central role of equipment and machinery necessitated expanded diagnostic and treatment areas (Fang, 2000). In the 1950s, several departments increased in size (e.g., surgery with clean cores, radiology with dedicated modality suites, and the emergency department with multiple “pod” clusters,) while in the 1960s, there developed a need for critical departmental adjacencies (e.g., emergency and radiology, labor/delivery and C-section ORs).
Thus, what we saw in the 1950s and 1960s was a shrinking of the bed floors and the enlarging of the D&T base. By the early 1970s, with new departments emerging (e.g., endoscopy), the ever-growing diagnostic and treatment departments, and desired adjacencies had forced the D&T base to become even larger and spread out.
The need for critical access and horizontal adjacencies to support these quickly evolving specialties resulted in labyrinthine floor plates filled with medically intense and frequently windowless spaces. Furthermore, the almost inevitable additions to these buildings compromised wayfinding and often eliminated the quantity and clarity of adjacent open space.
Many of these hospital designs are still all around us and, while they function from a basic medical operations point of view, are often disappointing in terms of scale, character, integrated open space, and, most importantly, the patient and staff experience. With an understanding of the potential benefits gleaned from vertical integration, a reconsideration of the bed tower on a D&T base seems overdue.
Two recent hospital designs take on the paradigm. Informed by a Corbusian tenet, these urban hospitals reclaim the considerable ground area lost by the diagnostic and treatment base, and transform it into expansive rooftop gardens that serve the entire campus (see images in gallery).
A hospital in a garden
The design of the new 1.5-million-square-foot, 900-patient-bed Jurong General Hospital in the Republic of Singapore required defining two major architectural moves: organizing the bed/clinical towers in a linear fashion to optimize open space and access, as well as the decision to build the main garden over the D&T base.
Jurong General Hospital’s site is bisected by a public road and resides in an urban mixed-use area of large-scale retail, mid-rise commercial, and high-rise residential buildings. The large program, natural ventilation requirements, height and lot coverage restrictions, and a client-driven focus on gardens were major forces that shaped the design solution.
Organizing the clinical bed towers
The simple systems of organization and circulation serve to offset the considerable size of the program. With the programmatic elements arranged as a series of semi-independent buildings placed end to end, simple racetrack corridors replace the maze-like paths often found in such complex facilities.